Healthcare Provider Details

I. General information

NPI: 1144678525
Provider Name (Legal Business Name): JASMINE IVETTE VILLALTA DE ALBA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 UNIVERSITY AVE
RIVERSIDE CA
92521-2694
US

IV. Provider business mailing address

PO BOX 362
RANCHO CUCAMONGA CA
91729-0362
US

V. Phone/Fax

Practice location:
  • Phone: 951-827-5531
  • Fax:
Mailing address:
  • Phone: 909-519-5016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number88229
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number88229
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: