Healthcare Provider Details

I. General information

NPI: 1639035603
Provider Name (Legal Business Name): JEANETTE NICOLE MAGGARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2026
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 ANIRA CT
PERRIS CA
92571-5113
US

IV. Provider business mailing address

484 GRANITE VIEW DR
PERRIS CA
92571-3330
US

V. Phone/Fax

Practice location:
  • Phone: 951-435-7199
  • Fax:
Mailing address:
  • Phone: 951-653-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1550020224
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: