Provider Demographics
NPI:1447616958
Name:HALAK, JENIECE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENIECE
Middle Name:
Last Name:HALAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 W PICO BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-4002
Mailing Address - Country:US
Mailing Address - Phone:213-383-3600
Mailing Address - Fax:
Practice Address - Street 1:2324 W PICO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-4002
Practice Address - Country:US
Practice Address - Phone:213-383-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53131OtherPA BOARD OF CALIFORNIA
CA53131OtherPA BOARD OF CALIFORNIA