Healthcare Provider Details

I. General information

NPI: 1063967719
Provider Name (Legal Business Name): ARYSSA JAZZMYNE MENDOZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4221 JONES AVE
RIVERSIDE CA
92505-2918
US

IV. Provider business mailing address

4221 JONES AVE
RIVERSIDE CA
92505-2918
US

V. Phone/Fax

Practice location:
  • Phone: 951-403-7698
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: