Provider Demographics
NPI:1962124719
Name:BRAVO SALAS, JAMIE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:BRAVO SALAS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 CHERRY LN STE 101
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-4311
Mailing Address - Country:US
Mailing Address - Phone:209-647-6200
Mailing Address - Fax:
Practice Address - Street 1:302 CHERRY LN STE 101
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-4311
Practice Address - Country:US
Practice Address - Phone:209-647-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 373H00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker