Healthcare Provider Details

I. General information

NPI: 1528615150
Provider Name (Legal Business Name): JESSICA TERESS CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7365 CARNELIAN ST STE 231
RANCHO CUCAMONGA CA
91730-1136
US

IV. Provider business mailing address

9517 REA AVE
CALIFORNIA CITY CA
93505-4831
US

V. Phone/Fax

Practice location:
  • Phone: 661-418-1129
  • Fax:
Mailing address:
  • Phone: 661-418-1129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number139061
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: