Provider Demographics
NPI:1669208674
Name:PLEWA, JAKE TIMOTHY (CGC)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:TIMOTHY
Last Name:PLEWA
Suffix:
Gender:M
Credentials:CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 GAYLEY AVE STE 391
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3441
Mailing Address - Country:US
Mailing Address - Phone:408-510-9802
Mailing Address - Fax:
Practice Address - Street 1:200 UCLA MEDICAL PLZ STE 120
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3441
Practice Address - Country:US
Practice Address - Phone:408-510-9802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGC001875170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS