Healthcare Provider Details

I. General information

NPI: 1104745512
Provider Name (Legal Business Name): BLOOMING PATHWAYS BEHAVIORAL HEALTH GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2026
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 ELSWORTH ST APT 108
MORENO VALLEY CA
92553-8437
US

IV. Provider business mailing address

13400 ELSWORTH ST APT 108
MORENO VALLEY CA
92553-8437
US

V. Phone/Fax

Practice location:
  • Phone: 951-796-0048
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: SIMONE ANGELIQUE JACKSON
Title or Position: CEO
Credential: MA, BCBA
Phone: 951-796-0048