Provider Demographics
NPI:1174174700
Name:VITALE, JENNA K (DAOM , LAC)
Entity type:Individual
Prefix:DR
First Name:JENNA
Middle Name:K
Last Name:VITALE
Suffix:
Gender:F
Credentials:DAOM , LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6711 FOREST LAWN DR STE 104
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-1032
Mailing Address - Country:US
Mailing Address - Phone:818-860-1314
Mailing Address - Fax:
Practice Address - Street 1:6711 FOREST LAWN DR STE 104
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90068-1032
Practice Address - Country:US
Practice Address - Phone:818-860-1314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18678171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist