Provider Demographics
NPI:1336576537
Name:STEPHENS, JUANETTA
Entity Type:Individual
Prefix:
First Name:JUANETTA
Middle Name:
Last Name:STEPHENS
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 1:6114 S VICTORIA AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-3997
Mailing Address - Country:US
Mailing Address - Phone:323-978-3900
Mailing Address - Fax:
Practice Address - Street 1:600 E 7TH ST STE 105
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90021-1439
Practice Address - Country:US
Practice Address - Phone:213-537-0110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7404Medicaid