Provider Demographics
NPI:1235786401
Name:PITTS, JERMELLE F
Entity Type:Individual
Prefix:
First Name:JERMELLE
Middle Name:F
Last Name:PITTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-1821
Mailing Address - Country:US
Mailing Address - Phone:323-751-3026
Mailing Address - Fax:
Practice Address - Street 1:832 FEDORA ST APT 207
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-2106
Practice Address - Country:US
Practice Address - Phone:310-779-9380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF7813708Medicaid