1821299744 NPI number — DR. LINDA SUSAN JOVANOVIC PH.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821299744 NPI number — DR. LINDA SUSAN JOVANOVIC PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOVANOVIC
Provider First Name:
LINDA
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821299744
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/27/2019
NPI Reactivation Date:
10/26/2021

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
234 CORNWALL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRASS VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95945-7117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-484-0710
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 ZION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEVADA CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95959-2922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-484-0710
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PSY 14437 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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