Healthcare Provider Details

I. General information

NPI: 1306017678
Provider Name (Legal Business Name): MS. JENNY MONDRAGON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. JENNY HEATH

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 FULTON MALL CCS, 2ND FLOOR
FRESNO CA
93721-1915
US

IV. Provider business mailing address

1221 FULTON MALL CCS, 2ND FLOOR
FRESNO CA
93721-1915
US

V. Phone/Fax

Practice location:
  • Phone: 559-445-3449
  • Fax: 559-445-3370
Mailing address:
  • Phone: 559-445-3449
  • Fax: 559-445-3370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number30385
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: