Healthcare Provider Details

I. General information

NPI: 1760238000
Provider Name (Legal Business Name): HAILIE JAYNE HURTADO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HAILIE JAYNE GRAHAM

II. Dates (important events)

Enumeration Date: 04/26/2024
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2081 BUSINESS CENTER DR
IRVINE CA
92612-1119
US

IV. Provider business mailing address

11402 HOMELAND AVE
WHITTIER CA
90604-3527
US

V. Phone/Fax

Practice location:
  • Phone: 657-500-1441
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15989
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: