Provider Demographics
NPI:1770821613
Name:POWELL, JESSICA MAITRI (LAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MAITRI
Last Name:POWELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MAITRI
Other - Last Name:SOLICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:134 MARNELL AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1521
Mailing Address - Country:US
Mailing Address - Phone:831-600-5330
Mailing Address - Fax:
Practice Address - Street 1:303 POTRERO ST
Practice Address - Street 2:#42-306
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2741
Practice Address - Country:US
Practice Address - Phone:831-459-6762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14747171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist