Provider Demographics
NPI:1366204786
Name:BABEL-BUCKNER, JONAS RAY
Entity type:Individual
Prefix:
First Name:JONAS
Middle Name:RAY
Last Name:BABEL-BUCKNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 CALAVERAS AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-3024
Mailing Address - Country:US
Mailing Address - Phone:916-826-8781
Mailing Address - Fax:
Practice Address - Street 1:584 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2779
Practice Address - Country:US
Practice Address - Phone:530-661-3213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker