Provider Demographics
NPI:1013501048
Name:SALAS, JESSICA MARIA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIA
Last Name:SALAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 MARENGO ST # C4J100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1352
Mailing Address - Country:US
Mailing Address - Phone:323-409-7469
Mailing Address - Fax:
Practice Address - Street 1:2051 MARENGO ST # C4J100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1352
Practice Address - Country:US
Practice Address - Phone:323-409-7469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-20
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95086022163W00000X
CA95017354363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse