Healthcare Provider Details

I. General information

NPI: 1720627656
Provider Name (Legal Business Name): JARED VALENZUELA L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3663 ARCH RD
STOCKTON CA
95215-8315
US

IV. Provider business mailing address

1948 LONGDON DR
STOCKTON CA
95206-4697
US

V. Phone/Fax

Practice location:
  • Phone: 209-943-2202
  • Fax:
Mailing address:
  • Phone: 209-601-5072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC18672
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: