Provider Demographics
NPI:1053596056
Name:FADA, JESSICA RAE (OTHER)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:RAE
Last Name:FADA
Suffix:
Gender:F
Credentials:OTHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15662 K ST
Mailing Address - Street 2:
Mailing Address - City:MOJAVE
Mailing Address - State:CA
Mailing Address - Zip Code:93501-1826
Mailing Address - Country:US
Mailing Address - Phone:661-824-4118
Mailing Address - Fax:661-824-4150
Practice Address - Street 1:15662 K ST
Practice Address - Street 2:
Practice Address - City:MOJAVE
Practice Address - State:CA
Practice Address - Zip Code:93501-1826
Practice Address - Country:US
Practice Address - Phone:661-824-4118
Practice Address - Fax:661-824-4150
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator