Provider Demographics
NPI:1710525860
Name:CANALES, JESSICA LEEANN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEEANN
Last Name:CANALES
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 1:107 S MILL ST STE B
Mailing Address - Street 2:
Mailing Address - City:TEHACHAPI
Mailing Address - State:CA
Mailing Address - Zip Code:93561-1619
Mailing Address - Country:US
Mailing Address - Phone:661-822-4639
Mailing Address - Fax:661-822-4951
Practice Address - Street 1:107 S MILL ST STE B
Practice Address - Street 2:
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-1619
Practice Address - Country:US
Practice Address - Phone:661-822-4639
Practice Address - Fax:661-822-4951
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist