Provider Demographics
NPI:1174822027
Name:TRAVERS, JEFFREY LYNNE
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:LYNNE
Last Name:TRAVERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12353 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-8305
Mailing Address - Country:US
Mailing Address - Phone:562-484-3385
Mailing Address - Fax:562-484-0269
Practice Address - Street 1:12353 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-8305
Practice Address - Country:US
Practice Address - Phone:562-484-3385
Practice Address - Fax:562-484-0269
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1512013461Medicaid
1512013461Medicare PIN
1512013461Medicare UPIN