Provider Demographics
NPI:1699536847
Name:JARNAGIN, TAYLOR COLETTE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:COLETTE
Last Name:JARNAGIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:COLETTE
Other - Last Name:LEEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1660 HOTEL CIR N STE 314
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-2803
Mailing Address - Country:US
Mailing Address - Phone:619-759-1548
Mailing Address - Fax:
Practice Address - Street 1:1660 HOTEL CIR N STE 314
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2803
Practice Address - Country:US
Practice Address - Phone:619-759-1548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA175T00000XMedicaid