Provider Demographics
NPI:1326684861
Name:LOCKE, AJA ELIS (MS)
Entity Type:Individual
Prefix:MISS
First Name:AJA
Middle Name:ELIS
Last Name:LOCKE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 E ORANGE GROVE AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-2884
Mailing Address - Country:US
Mailing Address - Phone:818-861-7175
Mailing Address - Fax:
Practice Address - Street 1:641 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-6201
Practice Address - Country:US
Practice Address - Phone:818-795-7847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABOC20000412052255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty