MEDICARE: DR. JASON VASQUEZ PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	29584	CA
2	103TC0700X	Clinical Psychologist	071.008407	IL

General Provider Information

NPI Number	:	1457609802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON VASQUEZ PH.D.

Provider Business Mailing Address
First Line	:	7065 INDIANA AVE STE 100&110
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-4167
Country	:	US
Telephone Number	:	760-647-7676
Fax Number	:	760-347-0909

Provider Business Practice Location Address
First Line	:	7065 INDIANA AVE STE 100&110
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-4167
Country	:	US
Telephone Number	:	760-647-7676
Fax Number	:	760-347-0909

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2012
Last Update Date	:	03/04/2026

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