1760965966 NPI number — MARIA FERNANDA JENKINSON CADC L CI22270620

Table of content: MARIA FERNANDA JENKINSON CADC L CI22270620 (NPI 1760965966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760965966 NPI number — MARIA FERNANDA JENKINSON CADC L CI22270620

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENKINSON
Provider First Name:
MARIA
Provider Middle Name:
FERNANDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CADC L CI22270620
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760965966
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10520 LAKESIDE DR N UNIT J
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARDEN GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92840-5060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-388-5506
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 E 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-4007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-542-2246
Provider Business Practice Location Address Fax Number:
714-906-0947
Provider Enumeration Date:
09/13/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  CI22270620 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CI22270620 . This is a "CCAPP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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