Provider Demographics
NPI:1962568865
Name:HUDDLESTON, JENNIFER (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HUDDLESTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N VERMONT AVE
Mailing Address - Street 2:SUITE 707
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6005
Mailing Address - Country:US
Mailing Address - Phone:323-913-4560
Mailing Address - Fax:323-913-4570
Practice Address - Street 1:1300 N VERMONT AVE
Practice Address - Street 2:SUITE 707
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6005
Practice Address - Country:US
Practice Address - Phone:323-913-4560
Practice Address - Fax:323-913-4570
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15171363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant