Healthcare Provider Details

I. General information

NPI: 1922634187
Provider Name (Legal Business Name): JENNAH N SPARACO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 06/15/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 CHERRY LN STE 101
MANTECA CA
95337-4311
US

IV. Provider business mailing address

2 S GREEN ST
SONORA CA
95370-4618
US

V. Phone/Fax

Practice location:
  • Phone: 209-647-6200
  • Fax:
Mailing address:
  • Phone: 209-533-6245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: