Healthcare Provider Details

I. General information

NPI: 1407259807
Provider Name (Legal Business Name): JESSICA PITTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2014
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11288 DANDELION LN
APPLE VALLEY CA
92308-3638
US

IV. Provider business mailing address

11288 DANDELION LN
APPLE VALLEY CA
92308-3638
US

V. Phone/Fax

Practice location:
  • Phone: 760-954-1286
  • Fax:
Mailing address:
  • Phone: 760-954-1286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: