Provider Demographics
NPI:1295993228
Name:EBACH, JASMINE SAMANTHA
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:SAMANTHA
Last Name:EBACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:SAMANTHA
Other - Last Name:ADRAGNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3254 SANDPIPER WAY
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-2227
Mailing Address - Country:US
Mailing Address - Phone:831-521-5565
Mailing Address - Fax:
Practice Address - Street 1:1270 NATIVIDAD RD
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906-3122
Practice Address - Country:US
Practice Address - Phone:831-755-4510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
CALMFT89393106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27BW8OtherMEDI-CAL PRV NBR
CA44CFOtherMEDI-CAL PRV NBR
CA27BW8OtherMEDI-CAL PRV NBR