Basic Information
| Provider Information | |||||||||
| NPI: | 1891376158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAFFERTY | ||||||||
| FirstName: | JENEVIEVE | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | LAFFERTY | ||||||||
| OtherFirstName: | JENNA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18726 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902483813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108560800 | ||||||||
| FaxNumber: | 8555682494 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 BONHOMME AVE STE 1800 | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631051931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362020693 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2021 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-21-160619 | MO | Y |
No ID Information.