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General NPI Number Information
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NPI Number | 1649034901
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Entity Type | Individual
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Provider Name | CANDYCE JILLSON AMDT
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Gender | Female
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Dates
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Enumeration Date | 02/07/2024
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Last Update Date | 02/07/2024
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Provider Practice Location Address
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Address Line | 2641 HAMNER AVE STE 201
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City | NORCO
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State | CA
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Zip | 92860-3637
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Country | US
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Telephone | 951-203-8737
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Fax |
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Provider Business Mailing Address
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Address Line | 1793 WREN AVE
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City | CORONA
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State | CA
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Zip | 92879-2939
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Country | US
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Telephone | 951-203-8737
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | AMFT110083
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License Number State | CA
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