Healthcare Provider Details

I. General information

NPI: 1609392935
Provider Name (Legal Business Name): JAQUELINNE GONZALEZ-RUIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2017
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14677 MERRILL AVE.
FONTANA CA
92335
US

IV. Provider business mailing address

14677 MERRILL AVE
FONTANA CA
92335-4219
US

V. Phone/Fax

Practice location:
  • Phone: 951-643-2335
  • Fax:
Mailing address:
  • Phone: 714-757-1529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number83889
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113832
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: