Healthcare Provider Details

I. General information

NPI: 1821772674
Provider Name (Legal Business Name): JESSICA OGUNDUYILE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 E GILBERT ST, SAN BERNADINO
SAN BERNARDINO CA
92404
US

IV. Provider business mailing address

1950 S SUNWEST LN STE 200
SAN BERNARDINO CA
92408-3248
US

V. Phone/Fax

Practice location:
  • Phone: 909-387-7194
  • Fax:
Mailing address:
  • Phone: 909-252-4017
  • Fax: 909-252-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: