Provider Demographics
NPI:1740906809
Name:SOONTHONTHUM, JENNYLAINE (MSN)
Entity type:Individual
Prefix:
First Name:JENNYLAINE
Middle Name:
Last Name:SOONTHONTHUM
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20534 CHERYL LN
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91350-5719
Mailing Address - Country:US
Mailing Address - Phone:626-221-2147
Mailing Address - Fax:
Practice Address - Street 1:1821 WILSHIRE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5679
Practice Address - Country:US
Practice Address - Phone:213-460-2442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032674363LP0808X
CA95041589163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WE0003XNursing Service ProvidersRegistered NurseEmergency