Provider Demographics
NPI:1427807239
Name:PRUDENCIO, JAMIE MICHELLE LALIS
Entity type:Individual
Prefix:
First Name:JAMIE MICHELLE
Middle Name:LALIS
Last Name:PRUDENCIO
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 1:3200 W TEMPLE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-7372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 W TEMPLE ST STE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-7372
Practice Address - Country:US
Practice Address - Phone:213-382-1819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker