Healthcare Provider Details

I. General information

NPI: 1194844290
Provider Name (Legal Business Name): MISS JAMIE DIANE ENOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MCHENRY VILLAGE WAY # 11
MODESTO CA
95350-4308
US

IV. Provider business mailing address

1700 MCHENRY VILLAGE WAY # 11
MODESTO CA
95350-4308
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-1476
  • Fax: 209-526-0908
Mailing address:
  • Phone: 209-526-1476
  • Fax: 209-526-0908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number52303
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: