Healthcare Provider Details

I. General information

NPI: 1558152017
Provider Name (Legal Business Name): JACOB A BRUCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2025
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

572 N ARROWHEAD AVE
SAN BERNARDINO CA
92401-1251
US

IV. Provider business mailing address

572 N ARROWHEAD AVE
SAN BERNARDINO CA
92401-1251
US

V. Phone/Fax

Practice location:
  • Phone: 909-266-2700
  • Fax: 909-266-2700
Mailing address:
  • Phone: 909-226-2700
  • Fax: 909-226-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPCC22677
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: