Healthcare Provider Details

I. General information

NPI: 1710404066
Provider Name (Legal Business Name): JOHN HEPHNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 07/21/2022
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 E ARROW HWY BLDG C
UPLAND CA
91786-4987
US

IV. Provider business mailing address

1260 E ARROW HWY BLDG C
UPLAND CA
91786-4987
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-1227
  • Fax:
Mailing address:
  • Phone: 909-932-1069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number114099
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: