Healthcare Provider Details

I. General information

NPI: 1962804807
Provider Name (Legal Business Name): JAHMEL DIOR ROVER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 11/04/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N ARROWHEAD AVE STE 300
SAN BERNARDINO CA
92401-1148
US

IV. Provider business mailing address

600 N ARROWHEAD AVE STE 300
SAN BERNARDINO CA
92401-1148
US

V. Phone/Fax

Practice location:
  • Phone: 909-763-5800
  • Fax: 909-882-1282
Mailing address:
  • Phone: 909-763-5800
  • Fax: 909-882-1282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number89947
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: