Healthcare Provider Details

I. General information

NPI: 1942013792
Provider Name (Legal Business Name): JESSICA ANNE IVY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7365 CARNELIAN ST STE 240
RANCHO CUCAMONGA CA
91730-1136
US

IV. Provider business mailing address

11651 RICHMOND ST
RIVERSIDE CA
92505-3259
US

V. Phone/Fax

Practice location:
  • Phone: 909-281-1557
  • Fax:
Mailing address:
  • Phone: 951-756-4185
  • Fax:

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: