Healthcare Provider Details

I. General information

NPI: 1740114180
Provider Name (Legal Business Name): JACK BARTLETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W LUGONIA AVE
REDLANDS CA
92374-2234
US

IV. Provider business mailing address

1000 PINE AVE APT 176
REDLANDS CA
92373-5504
US

V. Phone/Fax

Practice location:
  • Phone: 909-307-5300
  • Fax:
Mailing address:
  • Phone: 636-379-3527
  • 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: