Provider Demographics
NPI:1679384317
Name:VIZCARRA, JENNELYN ACEDERA
Entity type:Individual
Prefix:
First Name:JENNELYN
Middle Name:ACEDERA
Last Name:VIZCARRA
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 1:5810 DENNY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-1433
Mailing Address - Country:US
Mailing Address - Phone:818-818-2070
Mailing Address - Fax:
Practice Address - Street 1:18646 OXNARD ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-1486
Practice Address - Country:US
Practice Address - Phone:818-853-1928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA742996164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse