Healthcare Provider Details

I. General information

NPI: 1003716754
Provider Name (Legal Business Name): JAELYN RESHAWN PATTERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2026
Last Update Date: 11/06/2026
Certification Date: 11/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 LIGHTCAP ST
LANCASTER CA
93535-2704
US

IV. Provider business mailing address

1053 LIGHTCAP ST
LANCASTER CA
93535-2704
US

V. Phone/Fax

Practice location:
  • Phone: 661-519-8871
  • Fax:
Mailing address:
  • Phone: 661-519-8871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberU0677989
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: