Basic Information
| Provider Information | |||||||||
| NPI: | 1962096495 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHOUNTHAVONG | ||||||||
| FirstName: | JASMIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 730 S MARENGO AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911063886 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2051 MARENGO ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900331352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234091000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2021 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0705X | 95155200 | CA | Y | Nursing Service Providers | Registered Nurse | Medical-Surgical |
ID Information
| ID | Type | State | Issuer | Description | 11405746 | 01 | CA | KAISER | OTHER |