Healthcare Provider Details

I. General information

NPI: 1942122536
Provider Name (Legal Business Name): JAEDEN MARCUS RUDULPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5280 LITTLE MOUNTAIN DR APT P2
SAN BERNARDINO CA
92407-4938
US

IV. Provider business mailing address

5280 LITTLE MOUNTAIN DR APT P2
SAN BERNARDINO CA
92407-4938
US

V. Phone/Fax

Practice location:
  • Phone: 909-273-5283
  • Fax:
Mailing address:
  • Phone: 909-273-5283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: