Basic Information
| Provider Information | |||||||||
| NPI: | 1003283425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PONCE-SOLORIO | ||||||||
| FirstName: | JENNINE | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1195 N MARENGO AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911032645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263761534 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2550 E FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911073406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262545000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2015 | ||||||||
| LastUpdateDate: | 09/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.