Provider Demographics
NPI:1902453624
Name:SOSA BENAVIDES, JENNIFER MARILY
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARILY
Last Name:SOSA BENAVIDES
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 1:210 3/4 N AVENUE 53
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-4008
Mailing Address - Country:US
Mailing Address - Phone:323-479-9017
Mailing Address - Fax:
Practice Address - Street 1:50 N HILL AVE STE 100
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1949
Practice Address - Country:US
Practice Address - Phone:714-834-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician