Healthcare Provider Details

I. General information

NPI: 1801550652
Provider Name (Legal Business Name): MARY JOAN BRACKIN HEALTH COACH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11631 COHANSEY RD
SAN DIEGO CA
92131-3617
US

IV. Provider business mailing address

11631 COHANSEY RD
SAN DIEGO CA
92131-3617
US

V. Phone/Fax

Practice location:
  • Phone: 161-984-0603
  • Fax:
Mailing address:
  • Phone: 161-984-0603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberNONE
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: