Provider Demographics
NPI:1336516632
Name:WETHERBE, JESSIE (FNP)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:WETHERBE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 ADMIRALTY WAY
Mailing Address - Street 2:STE 105
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5424
Mailing Address - Country:US
Mailing Address - Phone:310-694-5255
Mailing Address - Fax:310-306-5555
Practice Address - Street 1:3400 LOMITA BLVD
Practice Address - Street 2:STE 607
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4909
Practice Address - Country:US
Practice Address - Phone:310-530-5363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002751363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily