Healthcare Provider Details

I. General information

NPI: 1992347199
Provider Name (Legal Business Name): JENNIFER ESCAMILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4424 CAPRI CIR
NORCO CA
92860-1309
US

IV. Provider business mailing address

4424 CAPRI CIR
NORCO CA
92860-1309
US

V. Phone/Fax

Practice location:
  • Phone: 951-733-3061
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3660
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: