MEDICARE: JESSICA GUILLEN

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	88600	CA

General Provider Information

NPI Number	:	1992108724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA GUILLEN

Provider Business Mailing Address
First Line	:	3445 ATWATER AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90039-1915
Country	:	US
Telephone Number	:	213-392-1124
Fax Number	:

Provider Business Practice Location Address
First Line	:	3445 ATWATER AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90039-1915
Country	:	US
Telephone Number	:	213-392-1124
Fax Number	:

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

Provider Enumeration Date	:	10/07/2014
Last Update Date	:	03/01/2021

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