Healthcare Provider Details

I. General information

NPI: 1043039910
Provider Name (Legal Business Name): JASMIN HERNANDEZ CADC I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11555 1/2 POTRERO RD
BANNING CA
92220-6946
US

IV. Provider business mailing address

15565 VIA MONTANA
DESERT HOT SPRINGS CA
92240-6925
US

V. Phone/Fax

Practice location:
  • Phone: 951-849-4761
  • Fax:
Mailing address:
  • Phone: 760-975-6511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI44340924
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: