Healthcare Provider Details

I. General information

NPI: 1508034158
Provider Name (Legal Business Name): JENNIFER MARIE MEDRANO-PAGE CADCII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2008
Last Update Date: 09/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12125 SHALE RIDGE LN
AUBURN CA
95602-8880
US

IV. Provider business mailing address

12125 SHALE RIDGE LN
AUBURN CA
95602-8880
US

V. Phone/Fax

Practice location:
  • Phone: 530-885-1917
  • Fax: 530-885-1189
Mailing address:
  • Phone: 308-851-9175
  • Fax: 530-885-1189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA010740315
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: