Provider Demographics
NPI:1083636203
Name:KOSOVA, JENNIFER R (PAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:KOSOVA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:LEVITT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:1439 N HIGHLAND AVE STE 1059
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7622
Mailing Address - Country:US
Mailing Address - Phone:214-455-5366
Mailing Address - Fax:323-336-8769
Practice Address - Street 1:1328 22ND STREET
Practice Address - Street 2:ER
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:214-455-5366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02208363A00000X
CAPA20131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S63849Medicare UPIN
CABN284XMedicare PIN
CABN284YMedicare UPIN