Healthcare Provider Details

I. General information

NPI: 1780317362
Provider Name (Legal Business Name): JESSE MAGANA CMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2022
Last Update Date: 07/01/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8807 THORNTON RD STE P
STOCKTON CA
95209-1863
US

IV. Provider business mailing address

PO BOX 6607
STOCKTON CA
95206-0607
US

V. Phone/Fax

Practice location:
  • Phone: 209-808-2581
  • Fax: 209-951-0448
Mailing address:
  • Phone: 209-808-2581
  • Fax: 209-951-0448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number55139
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: