1336516632 NPI number — JESSIE WETHERBE F.N.P.

Table of content: JESSIE WETHERBE F.N.P. (NPI 1336516632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336516632 NPI number — JESSIE WETHERBE F.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WETHERBE
Provider First Name:
JESSIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
F.N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336516632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4560 ADMIRALTY WAY
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
MARINA DEL REY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90292-5424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-694-5255
Provider Business Mailing Address Fax Number:
310-306-5555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 LOMITA BLVD
Provider Second Line Business Practice Location Address:
STE 607
Provider Business Practice Location Address City Name:
TORRANCE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90505-4909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-530-5363
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/21/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  95002751 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)