MEDICARE: MR. FREEBORN IDJADJA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1295468494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FREEBORN IDJADJA

Provider Business Mailing Address
First Line	:	2150 STOCKTON BLVD
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95817-1337
Country	:	US
Telephone Number	:	916-267-5091
Fax Number	:

Provider Business Practice Location Address
First Line	:	9130 NOLAN ST APT 281
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95758-7539
Country	:	US
Telephone Number	:	916-267-5091
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2022
Last Update Date	:	08/29/2024

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Directions to “ MR. FREEBORN IDJADJA ” Practice Location

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