Healthcare Provider Details

I. General information

NPI: 1497549117
Provider Name (Legal Business Name): JAQUELINE DE JESUS SERRANO LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 COMMERCENTER E STE 210
SAN BERNARDINO CA
92408-3424
US

IV. Provider business mailing address

1906 COMMERCENTER E STE 210
SAN BERNARDINO CA
92408-3424
US

V. Phone/Fax

Practice location:
  • Phone: 909-415-2373
  • Fax: 909-415-2373
Mailing address:
  • Phone: 909-415-2373
  • Fax: 909-415-2373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAMFT164172
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: