Provider Demographics
NPI:1679065486
Name:FREEMAN, JOETTA RAE I
Entity Type:Individual
Prefix:
First Name:JOETTA
Middle Name:RAE
Last Name:FREEMAN
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOJO
Other - Middle Name:
Other - Last Name:FREEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:JOJO
Mailing Address - Street 1:21600 OXNARD ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-4976
Mailing Address - Country:US
Mailing Address - Phone:818-345-2345
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:9400 INTERNATIONAL BLVD # 106
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94603-1444
Practice Address - Country:US
Practice Address - Phone:209-408-9951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst