Healthcare Provider Details

I. General information

NPI: 1285297556
Provider Name (Legal Business Name): JARED MATTHEW TRUJILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 S E ST STE 100
SAN BERNARDINO CA
92408-2706
US

IV. Provider business mailing address

2080 S E ST STE 100
SAN BERNARDINO CA
92408-2706
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-8989
  • Fax: 909-388-9195
Mailing address:
  • Phone: 909-433-9300
  • Fax: 909-388-9195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number119182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: