Provider Demographics
NPI:1528179447
Name:EKENGREN, JESSICA MARIA (DC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIA
Last Name:EKENGREN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28212 KELLY JOHNSON PKWY
Mailing Address - Street 2:STE 120
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-5085
Mailing Address - Country:US
Mailing Address - Phone:661-254-9400
Mailing Address - Fax:661-254-9495
Practice Address - Street 1:28212 KELLY JOHNSON PKWY
Practice Address - Street 2:STE 120
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-5085
Practice Address - Country:US
Practice Address - Phone:661-254-9400
Practice Address - Fax:661-254-9495
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27220111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU84906Medicare UPIN