Healthcare Provider Details

I. General information

NPI: 1508364159
Provider Name (Legal Business Name): JESSICA ORTEGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 ORANGE SHOW LN STE 107
SAN BERNARDINO CA
92408-2016
US

IV. Provider business mailing address

17216 SATICOY ST # 141
VAN NUYS CA
91406-2103
US

V. Phone/Fax

Practice location:
  • Phone: 909-371-1039
  • 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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: