Provider Demographics
NPI:1710125786
Name:FAJARDO, JAIME EMMANUEL (LVN)
Entity Type:Individual
Prefix:MR
First Name:JAIME
Middle Name:EMMANUEL
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 S KINGSLEY DR
Mailing Address - Street 2:APT. 307
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-1291
Mailing Address - Country:US
Mailing Address - Phone:213-385-6005
Mailing Address - Fax:
Practice Address - Street 1:3126 GLENROSE AVE
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-4328
Practice Address - Country:US
Practice Address - Phone:626-296-9812
Practice Address - Fax:626-296-9818
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA236322164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse