Provider Demographics
NPI:1073134219
Name:OGNJANOVIC-JASOVIC, MINA (IBCLC)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:OGNJANOVIC-JASOVIC
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17046 BURBANK BLVD APT 1
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1830
Mailing Address - Country:US
Mailing Address - Phone:818-915-0191
Mailing Address - Fax:
Practice Address - Street 1:17046 BURBANK BLVD APT 1
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1830
Practice Address - Country:US
Practice Address - Phone:818-915-0191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-31537174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
L-31537OtherIBCLC
CA0002894751-0001-8OtherCITY OF LOS ANGELES