Provider Demographics
NPI:1437619319
Name:SANDOVAL, JEANNISE (RECREATION THERAPIST)
Entity Type:Individual
Prefix:
First Name:JEANNISE
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:RECREATION THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13839 FAIRLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-2108
Mailing Address - Country:US
Mailing Address - Phone:562-480-9332
Mailing Address - Fax:
Practice Address - Street 1:330 GOLDEN SHR STE 250
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4270
Practice Address - Country:US
Practice Address - Phone:562-256-7550
Practice Address - Fax:800-985-5002
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5278-T103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst