Healthcare Provider Details

I. General information

NPI: 1992622583
Provider Name (Legal Business Name): JAIME BRANDON PONCE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4576 E SHIELDS AVE
FRESNO CA
93726-7220
US

IV. Provider business mailing address

989 2ND ST
SANGER CA
93657-2158
US

V. Phone/Fax

Practice location:
  • Phone: 559-240-9206
  • Fax:
Mailing address:
  • Phone: 559-581-8493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberSUDRC22711
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: