Provider Demographics
NPI:1710675236
Name:JUBRAN, JERRIUS
Entity Type:Individual
Prefix:
First Name:JERRIUS
Middle Name:
Last Name:JUBRAN
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 1:18 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-5007
Mailing Address - Country:US
Mailing Address - Phone:651-285-2319
Mailing Address - Fax:
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-660-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program