Healthcare Provider Details

I. General information

NPI: 1245064369
Provider Name (Legal Business Name): JASMINE RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18612 SANTA ANA AVE
BLOOMINGTON CA
92316-2639
US

IV. Provider business mailing address

2212 S AUGUSTA PL
ONTARIO CA
91761-5770
US

V. Phone/Fax

Practice location:
  • Phone: 909-421-7120
  • Fax:
Mailing address:
  • Phone: 909-938-0089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: