Provider Demographics
NPI:1538660584
Name:JEWELL, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:JEWELL
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 1:21600 OXNARD ST
Mailing Address - Street 2:SUITE1800
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367
Mailing Address - Country:US
Mailing Address - Phone:949-661-6753
Mailing Address - Fax:
Practice Address - Street 1:27127 CALLE ARROYO STE 1921
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-2765
Practice Address - Country:US
Practice Address - Phone:949-661-6753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-15-02507106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician