Provider Demographics
NPI:1306085196
Name:PETTY, JENNIFER
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:PETTY
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 1:4160 GRAND VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5214
Mailing Address - Country:US
Mailing Address - Phone:310-751-1101
Mailing Address - Fax:310-397-5827
Practice Address - Street 1:4160 GRAND VIEW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5214
Practice Address - Country:US
Practice Address - Phone:310-751-1101
Practice Address - Fax:310-397-5827
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASPA 9532355A2700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355A2700XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistAudiology Assistant