Basic Information
| Provider Information | |||||||||
| NPI: | 1285204644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROCKWELL | ||||||||
| FirstName: | JARRETT | ||||||||
| MiddleName: | ANDREW WINSLOW MINOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2768 BULA CT | ||||||||
| Address2: | |||||||||
| City: | ALTADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910014634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4044826791 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8142 SUNLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185828832 | ||||||||
| FaxNumber: | 8185828836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2021 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.