Healthcare Provider Details

I. General information

NPI: 1457204083
Provider Name (Legal Business Name): ALEXXA JADE PERDOMO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2026
Last Update Date: 02/14/2026
Certification Date: 02/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HARPST ST
ARCATA CA
95521-8222
US

IV. Provider business mailing address

1974 BIRKDALE AVE
UPLAND CA
91784-7975
US

V. Phone/Fax

Practice location:
  • Phone: 707-826-3011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: