Healthcare Provider Details

I. General information

NPI: 1669670089
Provider Name (Legal Business Name): JESSICA A. COLOCHO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 N LOOP RD
FORT IRWIN CA
92310
US

IV. Provider business mailing address

4138 CALICO AVE
PICO RIVERA CA
90660-1617
US

V. Phone/Fax

Practice location:
  • Phone: 760-383-5445
  • Fax:
Mailing address:
  • Phone: 562-842-6142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: