Provider Demographics
NPI:1053193177
Name:CANTRELL, JEFFREY ISAAC (MSN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ISAAC
Last Name:CANTRELL
Suffix:
Gender:M
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 W POMONA AVE UNIT 452
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-4853
Mailing Address - Country:US
Mailing Address - Phone:405-596-2850
Mailing Address - Fax:
Practice Address - Street 1:6801 PARK TER STE 525
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1542
Practice Address - Country:US
Practice Address - Phone:310-590-7435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027653363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty