Provider Demographics
NPI:1821554742
Name:LIPTAWAT, JENNIFER VAN (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:VAN
Last Name:LIPTAWAT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10515 BALBOA BLVD STE 355
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-6381
Mailing Address - Country:US
Mailing Address - Phone:818-360-0025
Mailing Address - Fax:818-360-0026
Practice Address - Street 1:10515 BALBOA BLVD STE 355
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6381
Practice Address - Country:US
Practice Address - Phone:818-360-0025
Practice Address - Fax:818-360-0026
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18409171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist