Provider Demographics
NPI:1811593205
Name:PINK, JAMAAL JAI
Entity Type:Individual
Prefix:
First Name:JAMAAL
Middle Name:JAI
Last Name:PINK
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 1:1309 E 9TH ST APT 14
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-8113
Mailing Address - Country:US
Mailing Address - Phone:323-809-3511
Mailing Address - Fax:
Practice Address - Street 1:5715 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-4131
Practice Address - Country:US
Practice Address - Phone:323-948-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker