Provider Demographics
NPI:1063476851
Name:JERDEN, MAKI S (APRN)
Entity Type:Individual
Prefix:
First Name:MAKI
Middle Name:S
Last Name:JERDEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 LOMITA BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5002
Mailing Address - Country:US
Mailing Address - Phone:310-784-6838
Mailing Address - Fax:
Practice Address - Street 1:3330 LOMITA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5002
Practice Address - Country:US
Practice Address - Phone:310-784-6838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19635363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004258671Medicaid
CT500001660Medicare ID - Type Unspecified
CT004258671Medicaid