Healthcare Provider Details

I. General information

NPI: 1235682089
Provider Name (Legal Business Name): MRS. JENNIFER PARKER HACKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER PARKER AYLWORTH

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST
LOMA LINDA CA
92357-4238
US

IV. Provider business mailing address

10259 STAFFORD ST
RANCHO CUCAMONGA CA
91730-3045
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 951-836-8622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13343
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: