Provider Demographics
NPI:1255972485
Name:IBARRA, JESSICA JASMIN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JASMIN
Last Name:IBARRA
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 1:382 DUTCHESS LN
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-7502
Mailing Address - Country:US
Mailing Address - Phone:510-363-4056
Mailing Address - Fax:
Practice Address - Street 1:400 ESTUDILLO AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4962
Practice Address - Country:US
Practice Address - Phone:510-352-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-29
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner