Provider Demographics
NPI:1093938037
Name:JARRETT, MICHELLE AMANDA
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:AMANDA
Last Name:JARRETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1039 S HOLLY PL
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-5212
Mailing Address - Country:US
Mailing Address - Phone:626-918-2629
Mailing Address - Fax:
Practice Address - Street 1:160 S 7TH AVE
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91746-3211
Practice Address - Country:US
Practice Address - Phone:626-961-8971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57545106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist