Provider Demographics
NPI:1275278681
Name:SIITIA, JASMINE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:SIITIA
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 1:1720 W 166TH ST
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4706
Mailing Address - Country:US
Mailing Address - Phone:310-720-5595
Mailing Address - Fax:
Practice Address - Street 1:235 W 9TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3711
Practice Address - Country:US
Practice Address - Phone:310-521-9209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-29
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1466280422101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)