Provider Demographics
NPI:1528386505
Name:HEAD, EMILY JASMINE (LAC, MAOM)
Entity Type:Individual
Prefix:MISS
First Name:EMILY
Middle Name:JASMINE
Last Name:HEAD
Suffix:
Gender:F
Credentials:LAC, MAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31360 HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-9270
Mailing Address - Country:US
Mailing Address - Phone:707-969-7679
Mailing Address - Fax:
Practice Address - Street 1:250 N MAIN ST
Practice Address - Street 2:SUITE E
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-3622
Practice Address - Country:US
Practice Address - Phone:707-969-7679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 13564171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist