Healthcare Provider Details

I. General information

NPI: 1114583440
Provider Name (Legal Business Name): KIERSTEN JADE KOVACH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39899 BALENTINE DR STE 110
NEWARK CA
94560-5356
US

IV. Provider business mailing address

PO BOX 33568
SAN DIEGO CA
92163-3568
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax: 619-374-7134
Mailing address:
  • Phone: 949-833-2237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-67028
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: