Healthcare Provider Details

I. General information

NPI: 1770759516
Provider Name (Legal Business Name): MR. JUSTIN HENRY MOONEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. JAKE HENRY MOONEY

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N PERRIS BLVD
PERRIS CA
92571-2811
US

IV. Provider business mailing address

1053 N D ST
SAN BERNARDINO CA
92410-3521
US

V. Phone/Fax

Practice location:
  • Phone: 909-886-1691
  • Fax: 909-881-8694
Mailing address:
  • Phone: 909-886-1691
  • Fax: 909-881-8694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: