=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053299594
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE REVELES SALCEDO PMHNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2025
-----------------------------------------------------
Last Update Date | 02/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16888 NISQUALLI RD STE 200-4
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-9703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-921-8953
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16888 NISQUALLI RD STE 200-4
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-9703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-502-8020
-----------------------------------------------------
Fax | 760-841-4208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 95036807
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------