Healthcare Provider Details

I. General information

NPI: 1275821175
Provider Name (Legal Business Name): JESSICA DANIELLE SECUYA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 INLAND EMPIRE BLVD SUITE C
ONTARIO CA
91764-4898
US

IV. Provider business mailing address

2940 INLAND EMPIRE BLVD SUITE C
ONTARIO CA
91764-4898
US

V. Phone/Fax

Practice location:
  • Phone: 909-458-1350
  • Fax: 909-579-8149
Mailing address:
  • Phone: 909-458-1350
  • Fax: 909-252-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: