Provider Demographics
NPI:1245503457
Name:MCKENRICK, JASEN A
Entity type:Individual
Prefix:MR
First Name:JASEN
Middle Name:A
Last Name:MCKENRICK
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 1:44630 MONTEREY AVE
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-3326
Mailing Address - Country:US
Mailing Address - Phone:760-863-5900
Mailing Address - Fax:760-863-5912
Practice Address - Street 1:80150 US HIGHWAY 111
Practice Address - Street 2:SUITE C2
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-8359
Practice Address - Country:US
Practice Address - Phone:760-863-5900
Practice Address - Fax:760-863-5912
Is Sole Proprietor?:No
Enumeration Date:2012-02-17
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA4122237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist