Provider Demographics
NPI:1245955707
Name:MAI, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MAI
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 1:12101 DALE AVE SPC 92
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-6702
Mailing Address - Country:US
Mailing Address - Phone:408-680-6957
Mailing Address - Fax:
Practice Address - Street 1:11460 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6030
Practice Address - Country:US
Practice Address - Phone:310-337-7115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302994225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist