Provider Demographics
NPI:1235722216
Name:TRUAX, JESSICA LEE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LEE
Last Name:TRUAX
Suffix:
Gender:F
Credentials:ATC
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Mailing Address - Street 1:10034 PALO ALTO ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1541
Mailing Address - Country:US
Mailing Address - Phone:626-695-3704
Mailing Address - Fax:
Practice Address - Street 1:800 W COVINA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2476
Practice Address - Country:US
Practice Address - Phone:626-695-3704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA090402210OtherNATIONAL ATHLETIC TRAINERS ASSOCIATION