MEDICARE: MR. JEZREEL MARTIN SUPETRAN

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	1041C0700X	Clinical Social Worker	61376	CA

General Provider Information

NPI Number	:	1629301213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEZREEL MARTIN SUPETRAN

Provider Business Mailing Address
First Line	:	1000 S FREMONT AVE UNIT 34
Second Line	:
City	:	ALHAMBRA
State	:	CA
Zip	:	91803-8867
Country	:	US
Telephone Number	:	626-997-4953
Fax Number	:

Provider Business Practice Location Address
First Line	:	1750 HEYWOOD ST UNIT B
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-6552
Country	:	US
Telephone Number	:	805-694-8368
Fax Number	:

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

Provider Enumeration Date	:	09/14/2009
Last Update Date	:	03/16/2026

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