Provider Demographics
NPI:1376102541
Name:CARMICHAEL, JADA
Entity Type:Individual
Prefix:
First Name:JADA
Middle Name:
Last Name:CARMICHAEL
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 1:1128 IRIS CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-3934
Mailing Address - Country:US
Mailing Address - Phone:951-992-9229
Mailing Address - Fax:
Practice Address - Street 1:802 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3104
Practice Address - Country:US
Practice Address - Phone:951-686-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician