Provider Demographics
NPI:1073743787
Name:WHITE, JEROME DAVID
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:DAVID
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEROME
Other - Middle Name:DAVID
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:11965 VENICE BLVD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3979
Mailing Address - Country:US
Mailing Address - Phone:323-533-8288
Mailing Address - Fax:
Practice Address - Street 1:11965 VENICE BLVD
Practice Address - Street 2:SUITE 209
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3979
Practice Address - Country:US
Practice Address - Phone:323-533-8288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-16
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 13505171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist