Provider Demographics
NPI:1124179072
Name:JARAVATA, MERCY QUINQUILERIA
Entity Type:Individual
Prefix:
First Name:MERCY
Middle Name:QUINQUILERIA
Last Name:JARAVATA
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:PO BOX 20055
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93034-0055
Mailing Address - Country:US
Mailing Address - Phone:805-483-2253
Mailing Address - Fax:805-483-2255
Practice Address - Street 1:2055 SAVIERS RD
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93033-3608
Practice Address - Country:US
Practice Address - Phone:805-483-2253
Practice Address - Fax:805-483-2255
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMERCEDITA58Medicare ID - Type UnspecifiedSUBTANCE USE DISORDER