Healthcare Provider Details

I. General information

NPI: 1083998454
Provider Name (Legal Business Name): FEDERICO ESCOBEDO JARQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 BOYS REPUBLIC DR
CHINO HILLS CA
91709-5447
US

IV. Provider business mailing address

1907 BOYS REPUBLIC DR
CHINO HILLS CA
91709-5447
US

V. Phone/Fax

Practice location:
  • Phone: 909-628-1217
  • Fax:
Mailing address:
  • Phone: 909-628-1217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4378
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number98269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: