Healthcare Provider Details

I. General information

NPI: 1063376523
Provider Name (Legal Business Name): DESHAWN JAHMAL EDGE-HUGHES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 S E ST
SAN BERNARDINO CA
92408-2773
US

IV. Provider business mailing address

2080 S E ST
SAN BERNARDINO CA
92408-2773
US

V. Phone/Fax

Practice location:
  • Phone: 909-388-9191
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number755587
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: