Provider Demographics
NPI:1497211957
Name:WINNICK, JENNIFER MARISSA (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARISSA
Last Name:WINNICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 S WESTGATE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8635 W 3RD ST STE 1090W
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6126
Practice Address - Country:US
Practice Address - Phone:310-659-0705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA656573363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant