Provider Demographics
NPI:1487825691
Name:BALBOA, JODY A
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:A
Last Name:BALBOA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:A
Other - Last Name:RUGGIERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:541 N SAN JACINTO ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-3107
Mailing Address - Country:US
Mailing Address - Phone:951-791-3031
Mailing Address - Fax:
Practice Address - Street 1:541 N. SAN JACINTO AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544
Practice Address - Country:US
Practice Address - Phone:951-791-3031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101168106H00000X
CA74091106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA956000930Medicaid