Provider Demographics
NPI:1154891125
Name:HERNANDEZ, JAZZLIN
Entity type:Individual
Prefix:
First Name:JAZZLIN
Middle Name:
Last Name:HERNANDEZ
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 1:111 W OCEAN BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4633
Mailing Address - Country:US
Mailing Address - Phone:562-204-6585
Mailing Address - Fax:818-241-6853
Practice Address - Street 1:111 W OCEAN BLVD FL 4
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4633
Practice Address - Country:US
Practice Address - Phone:562-204-6585
Practice Address - Fax:818-241-6853
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2023-10-19
Deactivation Date:2023-08-10
Deactivation Code:
Reactivation Date:2023-10-18
Provider Licenses
StateLicense IDTaxonomies
CA12367098103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst