Provider Demographics
NPI:1902133499
Name:ELMSTROM, JEANNIE (LAC)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:
Last Name:ELMSTROM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11340 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1608
Mailing Address - Country:US
Mailing Address - Phone:310-710-2110
Mailing Address - Fax:
Practice Address - Street 1:11340 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1608
Practice Address - Country:US
Practice Address - Phone:310-710-2110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC-7659171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist