Healthcare Provider Details

I. General information

NPI: 1225503261
Provider Name (Legal Business Name): JOANNA JAZMIN GAMARRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2018
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date: 01/28/2021
Reactivation Date: 03/19/2021

III. Provider practice location address

1501 HUGHES WAY STE 150
LONG BEACH CA
90810-1878
US

IV. Provider business mailing address

1501 HUGHES WAY STE 150
LONG BEACH CA
90810-1878
US

V. Phone/Fax

Practice location:
  • Phone: 310-221-6336
  • Fax:
Mailing address:
  • Phone: 310-221-6336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: