Provider Demographics
NPI:1265167795
Name:MKRTCHYAN, JESSICA LAUREN (LAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:MKRTCHYAN
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 1:580 E RIO GRANDE ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-2254
Mailing Address - Country:US
Mailing Address - Phone:818-621-3727
Mailing Address - Fax:
Practice Address - Street 1:2043 MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CA
Practice Address - Zip Code:91020-1604
Practice Address - Country:US
Practice Address - Phone:818-621-3727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X
CAAC19358171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No171400000XOther Service ProvidersHealth & Wellness Coach