Healthcare Provider Details

I. General information

NPI: 1386408342
Provider Name (Legal Business Name): KYRI JADE MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2024
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58471 29 PALMS HWY STE 102
YUCCA VALLEY CA
92284-5818
US

IV. Provider business mailing address

58471 29 PALMS HWY STE 102
YUCCA VALLEY CA
92284-5818
US

V. Phone/Fax

Practice location:
  • Phone: 760-853-4888
  • Fax:
Mailing address:
  • Phone: 760-853-4888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-CFQLOK
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: