Healthcare Provider Details

I. General information

NPI: 1194288118
Provider Name (Legal Business Name): JAMAL TYRONE LEDET-TRAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 CAMINO DEL RIO S
SAN DIEGO CA
92108-3531
US

IV. Provider business mailing address

4746 GUYMON ST REAR
SAN DIEGO CA
92102-3730
US

V. Phone/Fax

Practice location:
  • Phone: 619-287-8225
  • Fax:
Mailing address:
  • Phone:
  • 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 Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: