Provider Demographics
NPI:1215594742
Name:PACIFICAR, JEROSSALYN GAZA
Entity Type:Individual
Prefix:
First Name:JEROSSALYN
Middle Name:GAZA
Last Name:PACIFICAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 N EDGEMONT ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-2611
Mailing Address - Country:US
Mailing Address - Phone:323-356-7241
Mailing Address - Fax:
Practice Address - Street 1:135 N PARK VIEW ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5215
Practice Address - Country:US
Practice Address - Phone:213-908-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB8117058OtherDRIVERS LICENSE