Healthcare Provider Details

I. General information

NPI: 1164058491
Provider Name (Legal Business Name): CRYSTAL RAQUEL JARA BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13001 RAMONA BLVD STE A
IRWINDALE CA
91706-3752
US

IV. Provider business mailing address

940 AVENUE 64
PASADENA CA
91105-2711
US

V. Phone/Fax

Practice location:
  • Phone: 323-254-2274
  • Fax:
Mailing address:
  • Phone: 323-543-2800
  • Fax: 323-978-1263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: