Provider Demographics
NPI:1982219994
Name:SAUCEDO, JEANETTE ABIGAIL
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:ABIGAIL
Last Name:SAUCEDO
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 1:9203 HARNESS ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-4211
Mailing Address - Country:US
Mailing Address - Phone:619-796-8950
Mailing Address - Fax:
Practice Address - Street 1:8291 LA MESA BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-5248
Practice Address - Country:US
Practice Address - Phone:858-529-1250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59879225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0012086125OtherKAISER PERMANENTE