Provider Demographics
NPI:1356827323
Name:GHARZEDDINE, JENNA ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:ROSE
Last Name:GHARZEDDINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 E CESAR E CHAVEZ AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2414
Mailing Address - Country:US
Mailing Address - Phone:323-268-5000
Mailing Address - Fax:
Practice Address - Street 1:2876 SYCAMORE DR STE 101
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1550
Practice Address - Country:US
Practice Address - Phone:805-527-6424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA160972207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program