Provider Demographics
NPI:1790304194
Name:TY-DE GUZMAN, JENNIFER O (MSN, FNP,DNP,PMHNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:O
Last Name:TY-DE GUZMAN
Suffix:
Gender:F
Credentials:MSN, FNP,DNP,PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14023 PARAMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-2605
Mailing Address - Country:US
Mailing Address - Phone:562-988-3370
Mailing Address - Fax:562-988-3373
Practice Address - Street 1:14023 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-2605
Practice Address - Country:US
Practice Address - Phone:562-988-3370
Practice Address - Fax:562-988-3373
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA508898163WH0200X
CA12561363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA08212FMedicaid