Healthcare Provider Details

I. General information

NPI: 1912451766
Provider Name (Legal Business Name): HEATHER JEBANANTHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PRISON RD
REPRESA CA
95671-3000
US

IV. Provider business mailing address

100 PRISON RD
REPRESA CA
95671-3000
US

V. Phone/Fax

Practice location:
  • Phone: 916-985-8610
  • Fax:
Mailing address:
  • Phone: 916-985-8610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY31844
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: