Healthcare Provider Details

I. General information

NPI: 1962255752
Provider Name (Legal Business Name): JENNIFER LYNN YAGHOUBIAN PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. JENNIFER LYNN CROFT

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 CRAFTON AVE
MENTONE CA
92359-1318
US

IV. Provider business mailing address

20 W LUGONIA AVE
REDLANDS CA
92374-2234
US

V. Phone/Fax

Practice location:
  • Phone: 909-800-4679
  • Fax:
Mailing address:
  • Phone: 909-800-4679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number200065241
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: