Healthcare Provider Details

I. General information

NPI: 1295618924
Provider Name (Legal Business Name): JESSE EUGENE SIERRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 S SUNWEST LN STE 200
SAN BERNARDINO CA
92408-3248
US

IV. Provider business mailing address

1950 S SUNWEST LN STE 200
SAN BERNARDINO CA
92408-3248
US

V. Phone/Fax

Practice location:
  • Phone: 909-252-4017
  • Fax:
Mailing address:
  • Phone: 909-252-4017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: