Provider Demographics
NPI:1063123339
Name:EVELETH, JESSICA ELAINE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELAINE
Last Name:EVELETH
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 1:500 N ELECTRIC AVE FRNT
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-2095
Mailing Address - Country:US
Mailing Address - Phone:971-808-7022
Mailing Address - Fax:
Practice Address - Street 1:500 N ELECTRIC AVE FRNT
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-2095
Practice Address - Country:US
Practice Address - Phone:971-808-7022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19617171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist