Provider Demographics
NPI:1316517154
Name:BRAVO, BRENDA JAZZLYN
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:JAZZLYN
Last Name:BRAVO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAZZLYN
Other - Middle Name:
Other - Last Name:BRAVO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5086 BLACK OAK RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-4517
Mailing Address - Country:US
Mailing Address - Phone:925-586-8263
Mailing Address - Fax:
Practice Address - Street 1:2919 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3917
Practice Address - Country:US
Practice Address - Phone:415-229-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program