Healthcare Provider Details

I. General information

NPI: 1912377953
Provider Name (Legal Business Name): JENNIFER M SANDOVAL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26266 MERIDIAN ST
HEMET CA
92544-6486
US

IV. Provider business mailing address

26266 MERIDIAN ST
HEMET CA
92544-6486
US

V. Phone/Fax

Practice location:
  • Phone: 657-217-1141
  • Fax: 657-202-1898
Mailing address:
  • Phone: 657-217-1141
  • Fax: 657-217-1141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY27635
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY27635
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY27635
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: