MEDICARE: JACQUELINE MURPHY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	RS5053	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5342	OTHER	CA	SIMON STAFF NUMBER

General Provider Information

NPI Number	:	1376753525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE MURPHY

Provider Business Mailing Address
First Line	:	PO BOX 7369
Second Line	:
City	:	REDLANDS
State	:	CA
Zip	:	92375-0369
Country	:	US
Telephone Number	:	909-335-7067
Fax Number	:	909-792-2045

Provider Business Practice Location Address
First Line	:	939 AND 955 N D ST
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92418-0001
Country	:	US
Telephone Number	:	909-381-5100
Fax Number	:	909-381-5101

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/08/2007

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