Healthcare Provider Details

I. General information

NPI: 1740719236
Provider Name (Legal Business Name): JESSICA MARIE REQUEJO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9445 FAIRWAY VIEW PL STE 100
RANCHO CUCAMONGA CA
91730-0930
US

IV. Provider business mailing address

34428 YUCAIPA BLVD # E178
YUCAIPA CA
92399-2474
US

V. Phone/Fax

Practice location:
  • Phone: 909-983-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number84003
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number105453
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: