Provider Demographics
NPI:1942901442
Name:FAULKNER, JAMES WINDFRED
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:WINDFRED
Last Name:FAULKNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7281 DUMOSA AVE STE 3&4
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-3769
Mailing Address - Country:US
Mailing Address - Phone:760-853-4755
Mailing Address - Fax:760-513-9717
Practice Address - Street 1:7281 DUMOSA AVE STE 4
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-3781
Practice Address - Country:US
Practice Address - Phone:760-853-4755
Practice Address - Fax:760-513-9717
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAMPSS-JTKRCO175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator