Provider Demographics
NPI:1790013399
Name:CHOTIRAWI, JENINE ANDREA (EDS)
Entity Type:Individual
Prefix:
First Name:JENINE
Middle Name:ANDREA
Last Name:CHOTIRAWI
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:JENINE
Other - Middle Name:ANDREA
Other - Last Name:GUTIERREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:616 N RECORD AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-1838
Mailing Address - Country:US
Mailing Address - Phone:323-273-1903
Mailing Address - Fax:
Practice Address - Street 1:616 N RECORD AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90063-1838
Practice Address - Country:US
Practice Address - Phone:323-273-1903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA090183898103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool