Provider Demographics
NPI:1679856033
Name:JEM, JASON
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:JEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4489 SPENCER ST
Mailing Address - Street 2:#112
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-2454
Mailing Address - Country:US
Mailing Address - Phone:310-977-9160
Mailing Address - Fax:
Practice Address - Street 1:4489 SPENCER ST
Practice Address - Street 2:#112
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-2454
Practice Address - Country:US
Practice Address - Phone:310-977-9160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA953893470Medicaid
CA953893470Medicare PIN
CA953893470Medicare UPIN
CA953893470Medicaid