Healthcare Provider Details

I. General information

NPI: 1457609802
Provider Name (Legal Business Name): JASON VASQUEZ PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7065 INDIANA AVE STE 110
RIVERSIDE CA
92506-4167
US

IV. Provider business mailing address

PO BOX 474
RANCHO CUCAMONGA CA
91729-0474
US

V. Phone/Fax

Practice location:
  • Phone: 951-394-1423
  • Fax:
Mailing address:
  • Phone: 951-394-1423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.008407
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number29584
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: