Healthcare Provider Details

I. General information

NPI: 1184587099
Provider Name (Legal Business Name): JESSICA NICOLE EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11801 PIERCE ST
RIVERSIDE CA
92505-4408
US

IV. Provider business mailing address

15105 PASTURE WAY
VICTORVILLE CA
92394-7429
US

V. Phone/Fax

Practice location:
  • Phone: 866-478-3978
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number134723
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: