Provider Demographics
NPI:1285654764
Name:GARNETT, MARY JANE (AUD)
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:GARNETT
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 LONE TREE WAY
Mailing Address - Street 2:STE D
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-6206
Mailing Address - Country:US
Mailing Address - Phone:925-778-3298
Mailing Address - Fax:925-778-0937
Practice Address - Street 1:4045 LONE TREE WAY
Practice Address - Street 2:SUITE D
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-6200
Practice Address - Country:US
Practice Address - Phone:925-778-3298
Practice Address - Fax:925-778-0937
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU473231H00000X
CAHA3465237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0004730Medicaid
CAAU0004730Medicaid