Healthcare Provider Details

I. General information

NPI: 1982039970
Provider Name (Legal Business Name): JESSICA GARDENIA VAJARAKITIPONGSE OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA GARDENIA ABAD OTR

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 S MAIN ST STE 205
CORONA CA
92882-2533
US

IV. Provider business mailing address

747 LASSEN DR
CORONA CA
92879-5980
US

V. Phone/Fax

Practice location:
  • Phone: 951-475-1307
  • Fax: 951-475-1308
Mailing address:
  • Phone: 951-751-8612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number11386
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: