Healthcare Provider Details

I. General information

NPI: 1972050763
Provider Name (Legal Business Name): ODYSSEY JASMIN CONTRERAS ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25455 BARTON RD STE 102B
LOMA LINDA CA
92354-3139
US

IV. Provider business mailing address

25455 BARTON RD STE 102B
LOMA LINDA CA
92354-3139
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-2808
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67286
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: