Provider Demographics
NPI:1902145022
Name:JALABA, TRACY (OT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:JALABA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-3340
Mailing Address - Fax:
Practice Address - Street 1:1640 MARENGO ST
Practice Address - Street 2:SUITE 500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1036
Practice Address - Country:US
Practice Address - Phone:323-442-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAOT14814225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOT14814OtherCA LICENSE