Healthcare Provider Details

I. General information

NPI: 1316182488
Provider Name (Legal Business Name): JACQUELINE MARIE DERAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 N GRAND AVE
COVINA CA
91724
US

IV. Provider business mailing address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

V. Phone/Fax

Practice location:
  • Phone: 626-859-2089
  • Fax: 626-859-6537
Mailing address:
  • Phone: 909-427-6440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number91426
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: