Provider Demographics
NPI:1891475869
Name:WAINSCOTT, JACOB RYAN (CMT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RYAN
Last Name:WAINSCOTT
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8041 REDLANDS ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-8356
Mailing Address - Country:US
Mailing Address - Phone:760-382-1090
Mailing Address - Fax:
Practice Address - Street 1:2001 S BARRINGTON AVE STE 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5337
Practice Address - Country:US
Practice Address - Phone:310-429-9385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90432225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist