Healthcare Provider Details

I. General information

NPI: 1265909204
Provider Name (Legal Business Name): JACK RUDY HENLEY CST-LL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 GEER RD STE 120
TURLOCK CA
95382-2456
US

IV. Provider business mailing address

2101 GEER RD STE 120
TURLOCK CA
95382-2456
US

V. Phone/Fax

Practice location:
  • Phone: 209-664-8044
  • Fax: 209-541-2114
Mailing address:
  • Phone: 209-664-8044
  • Fax: 209-541-2114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-FHKIAJ
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: