Provider Demographics
NPI:1801578489
Name:CARMONA, JAINE GONZALEZ
Entity type:Individual
Prefix:
First Name:JAINE
Middle Name:GONZALEZ
Last Name:CARMONA
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 1:49531 REYES ST
Mailing Address - Street 2:
Mailing Address - City:COACHELLA
Mailing Address - State:CA
Mailing Address - Zip Code:92236-1373
Mailing Address - Country:US
Mailing Address - Phone:760-619-0983
Mailing Address - Fax:
Practice Address - Street 1:44105 JACKSON ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3280
Practice Address - Country:US
Practice Address - Phone:909-755-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty