Provider Demographics
NPI:1568060184
Name:CATO-JACK, SIMONE A
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:A
Last Name:CATO-JACK
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 1:12917 CERISE AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5520
Mailing Address - Country:US
Mailing Address - Phone:310-675-4431
Mailing Address - Fax:
Practice Address - Street 1:12917 CERISE AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-5520
Practice Address - Country:US
Practice Address - Phone:310-675-4431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00965263376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty