MEDICARE: JESSICA R. IVEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1437435427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA R. IVEY

Provider Business Mailing Address
First Line	:	1680 VINE ST
Second Line	:	SUITE 305
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-8804
Country	:	US
Telephone Number	:	323-467-8466
Fax Number	:

Provider Business Practice Location Address
First Line	:	1680 VINE ST
Second Line	:	SUITE 305
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-8804
Country	:	US
Telephone Number	:	323-467-8466
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2011
Last Update Date	:	09/19/2012

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