Healthcare Provider Details

I. General information

NPI: 1225434392
Provider Name (Legal Business Name): JACKELINE GUZMAN GONZALEZ LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 CHICAGO AVE
RIVERSIDE CA
92507-2366
US

IV. Provider business mailing address

11818 LEWISIA AVE
MORENO VALLEY CA
92557-8608
US

V. Phone/Fax

Practice location:
  • Phone: 951-465-3664
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT158699
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: