Provider Demographics
NPI:1790562502
Name:POTES MANGRA, JAZMIN
Entity Type:Individual
Prefix:
First Name:JAZMIN
Middle Name:
Last Name:POTES MANGRA
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 1:2212A METCALF ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96822-2437
Mailing Address - Country:US
Mailing Address - Phone:612-226-2553
Mailing Address - Fax:
Practice Address - Street 1:2212A METCALF ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96822-2437
Practice Address - Country:US
Practice Address - Phone:612-226-2553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker