Healthcare Provider Details

I. General information

NPI: 1982529558
Provider Name (Legal Business Name): JERILYN OTTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 W GLADSTONE ST
SAN DIMAS CA
91773-1611
US

IV. Provider business mailing address

1314 W GLADSTONE ST
SAN DIMAS CA
91773-1611
US

V. Phone/Fax

Practice location:
  • Phone: 909-971-8204
  • Fax: 909-971-8254
Mailing address:
  • Phone: 909-971-8204
  • Fax: 909-971-8254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number13561
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: