Provider Demographics
NPI:1871942011
Name:JACA, SHEPELL OMEGA
Entity type:Individual
Prefix:MRS
First Name:SHEPELL
Middle Name:OMEGA
Last Name:JACA
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 1:3375 S HOOVER ST
Mailing Address - Street 2:SUITE H201
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-0116
Mailing Address - Country:US
Mailing Address - Phone:213-821-5930
Mailing Address - Fax:
Practice Address - Street 1:3375 S HOOVER ST
Practice Address - Street 2:SUITE H201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0116
Practice Address - Country:US
Practice Address - Phone:213-821-5930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60021960390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program