Provider Demographics
NPI:1851727127
Name:PRESTON, JAIME RONNEA
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:RONNEA
Last Name:PRESTON
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 1:1460 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-1418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1460 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-1418
Practice Address - Country:US
Practice Address - Phone:323-326-7564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20305174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist