Healthcare Provider Details

I. General information

NPI: 1366733438
Provider Name (Legal Business Name): JACQUELINE HEIDI RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E HOLT AVE
POMONA CA
91767-5406
US

IV. Provider business mailing address

6170 PEGASUS DR APT 5
RIVERSIDE CA
92503-8050
US

V. Phone/Fax

Practice location:
  • Phone: 909-620-2521
  • Fax:
Mailing address:
  • Phone: 619-867-9672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: