Provider Demographics
NPI:1235667619
Name:DE LEON, JESSICA E (LAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:DE LEON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3982 INGLEWOOD BLVD APT 7
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-4533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10801 NATIONAL BLVD
Practice Address - Street 2:SUITE 254
Practice Address - City:LA
Practice Address - State:CA
Practice Address - Zip Code:90064
Practice Address - Country:US
Practice Address - Phone:310-384-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17623171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC17623OtherACUPUNCTURE