Healthcare Provider Details

I. General information

NPI: 1265021653
Provider Name (Legal Business Name): JILL REYNA-CANALES ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 MERCEY SPRINGS RD
LOS BANOS CA
93635-3878
US

IV. Provider business mailing address

PO BOX 2409
LOS BANOS CA
93635-2409
US

V. Phone/Fax

Practice location:
  • Phone: 209-726-3090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberASW121602
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: