Provider Demographics
NPI:1215583414
Name:DETWILER, JESLYNN
Entity Type:Individual
Prefix:
First Name:JESLYNN
Middle Name:
Last Name:DETWILER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 S ESCONDIDO BLVD UNIT 108
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-7072
Mailing Address - Country:US
Mailing Address - Phone:801-430-5372
Mailing Address - Fax:
Practice Address - Street 1:15708 POMERADO RD STE 102N
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2035
Practice Address - Country:US
Practice Address - Phone:858-746-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician