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General NPI Number Information
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NPI Number | 1326500232
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Entity Type | Individual
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Provider Name | JETTE FUNK
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Gender | Female
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Dates
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Enumeration Date | 04/01/2019
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Last Update Date | 04/01/2019
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Provider Practice Location Address
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Address Line | 12235 BEACH BLVD
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City | STANTON
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State | CA
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Zip | 90680-3939
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Country | US
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Telephone | 714-202-0118
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Fax |
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Provider Business Mailing Address
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Address Line | 20432 GRAYSTONE LN
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92646-5332
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Country | US
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Telephone | 949-201-5500
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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