Healthcare Provider Details

I. General information

NPI: 1154106946
Provider Name (Legal Business Name): JEVONNE FOSTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15217 SAN BERNARDINO AVE
FONTANA CA
92335-5327
US

IV. Provider business mailing address

15217 SAN BERNARDINO AVE
FONTANA CA
92335-5327
US

V. Phone/Fax

Practice location:
  • Phone: 909-908-6496
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number36476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: