Healthcare Provider Details

I. General information

NPI: 1023602943
Provider Name (Legal Business Name): ADA BRENDA JARA MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2021
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72490 EL CENTRO WAY APT 117
THOUSAND PALMS CA
92276-3434
US

IV. Provider business mailing address

PO BOX 143
THOUSAND PALMS CA
92276-0143
US

V. Phone/Fax

Practice location:
  • Phone: 760-464-8849
  • Fax:
Mailing address:
  • Phone: 760-464-8849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number56366
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: