Provider Demographics
NPI:1790386753
Name:BANKO, JADA (DACM)
Entity Type:Individual
Prefix:
First Name:JADA
Middle Name:
Last Name:BANKO
Suffix:
Gender:F
Credentials:DACM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4482 LOUISIANA ST APT 6
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4105
Mailing Address - Country:US
Mailing Address - Phone:616-856-8640
Mailing Address - Fax:
Practice Address - Street 1:4514 BONITA RD
Practice Address - Street 2:
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-1427
Practice Address - Country:US
Practice Address - Phone:619-470-4714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18972171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist