Provider Demographics
NPI:1740775451
Name:JORY, CRISTENE ADEL (HHP, AWC)
Entity Type:Individual
Prefix:
First Name:CRISTENE
Middle Name:ADEL
Last Name:JORY
Suffix:
Gender:F
Credentials:HHP, AWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550018
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96155-0018
Mailing Address - Country:US
Mailing Address - Phone:530-517-0637
Mailing Address - Fax:
Practice Address - Street 1:3200 US HIGHWAY 50 UNIT 5
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-9207
Practice Address - Country:US
Practice Address - Phone:530-517-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225700000X, 405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist