Healthcare Provider Details

I. General information

NPI: 1720884968
Provider Name (Legal Business Name): JAZMINE A GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2025
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4990 ARLINGTON AVE STE D
RIVERSIDE CA
92504-2757
US

IV. Provider business mailing address

742 W HIGHLAND AVE
SAN BERNARDINO CA
92405-3839
US

V. Phone/Fax

Practice location:
  • Phone: 951-785-9011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: