Provider Demographics
NPI:1407533995
Name:VELASCO, JENNIFER MUNSAYAC
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MUNSAYAC
Last Name:VELASCO
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 1:1401 MISSION ST UNIT C5
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3287
Mailing Address - Country:US
Mailing Address - Phone:714-767-6623
Mailing Address - Fax:
Practice Address - Street 1:1401 MISSION ST UNIT C5
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3287
Practice Address - Country:US
Practice Address - Phone:714-767-6623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026633207Q00000X, 208000000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics