Healthcare Provider Details

I. General information

NPI: 1770344988
Provider Name (Legal Business Name): JADE LEE LEVONIAN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 06/19/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 S AUBURN ST
GRASS VALLEY CA
95945-7226
US

IV. Provider business mailing address

PO BOX 1151
GRASS VALLEY CA
95945-1151
US

V. Phone/Fax

Practice location:
  • Phone: 831-332-3584
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number19950
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: