Healthcare Provider Details

I. General information

NPI: 1962347138
Provider Name (Legal Business Name): JESSICA HADERLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 CALLE CAMISA
SAN CLEMENTE CA
92673-2703
US

IV. Provider business mailing address

719 CALLE CAMISA
SAN CLEMENTE CA
92673-2703
US

V. Phone/Fax

Practice location:
  • Phone: 949-429-9979
  • Fax:
Mailing address:
  • Phone: 949-429-9979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW136267
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: