Provider Demographics
NPI:1386133411
Name:GAMBLE, JAN MICHAEL (AUD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:MICHAEL
Last Name:GAMBLE
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:MICHAEL
Other - Last Name:DE LA CRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:756 S DORA ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5336
Mailing Address - Country:US
Mailing Address - Phone:707-463-2966
Mailing Address - Fax:
Practice Address - Street 1:756 S DORA ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5336
Practice Address - Country:US
Practice Address - Phone:707-463-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11580237600000X
CA8189237700000X
CA3358237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist