Healthcare Provider Details

I. General information

NPI: 1992338271
Provider Name (Legal Business Name): JERRY TURNER LEP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2020
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1584 GREEN CREEK TRL
BEAUMONT CA
92223-7365
US

IV. Provider business mailing address

1584 GREEN CREEK TRL
BEAUMONT CA
92223-7365
US

V. Phone/Fax

Practice location:
  • Phone: 951-453-8721
  • Fax:
Mailing address:
  • Phone: 951-453-8721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2966
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: