Provider Demographics
NPI:1164857546
Name:CRADDOCK, JAIH BONIQUE (MA)
Entity Type:Individual
Prefix:MRS
First Name:JAIH
Middle Name:BONIQUE
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MISS
Other - First Name:JAIH
Other - Middle Name:BONIQUE
Other - Last Name:MCREYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1111 WILSHIRE BLVD APT 526
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-2848
Mailing Address - Country:US
Mailing Address - Phone:510-926-8412
Mailing Address - Fax:
Practice Address - Street 1:9101 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-2405
Practice Address - Country:US
Practice Address - Phone:323-562-4016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program