Healthcare Provider Details

I. General information

NPI: 1710525860
Provider Name (Legal Business Name): JESSICA LEEANN CANALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S MILL ST STE B
TEHACHAPI CA
93561-1619
US

IV. Provider business mailing address

107 S MILL ST STE B
TEHACHAPI CA
93561-1619
US

V. Phone/Fax

Practice location:
  • Phone: 661-822-4639
  • Fax: 661-822-4951
Mailing address:
  • Phone: 661-822-4639
  • Fax: 661-822-4951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: