Healthcare Provider Details

I. General information

NPI: 1396527446
Provider Name (Legal Business Name): JESSE MORAN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1359 N GRAND AVE FL 2
COVINA CA
91724-1016
US

IV. Provider business mailing address

1359 N GRAND AVE FL 2
COVINA CA
91724-1016
US

V. Phone/Fax

Practice location:
  • Phone: 626-430-2901
  • Fax:
Mailing address:
  • Phone: 626-430-2901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: