Healthcare Provider Details

I. General information

NPI: 1992520001
Provider Name (Legal Business Name): NICOLE JOYNER PEER SUPPORT
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3286 E GUASTI RD
ONTARIO CA
91761-8645
US

IV. Provider business mailing address

2580 STATE ST
CORONA CA
92881-4150
US

V. Phone/Fax

Practice location:
  • Phone: 909-906-9844
  • Fax:
Mailing address:
  • Phone: 801-651-4764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMPSS-DHLENP
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: