Healthcare Provider Details

I. General information

NPI: 1114540598
Provider Name (Legal Business Name): KENNYANNA JEFFERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17053 FOOTHILL BLVD
FONTANA CA
92335-3574
US

IV. Provider business mailing address

850 E FOOTHILL BLVD
RIALTO CA
92376-5230
US

V. Phone/Fax

Practice location:
  • Phone: 909-347-1300
  • Fax: 909-347-1302
Mailing address:
  • Phone: 909-420-9472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number102016
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW102016
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number127688
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: