Provider Demographics
NPI:1235492612
Name:MOSSON, JENNIFER FAY
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:FAY
Last Name:MOSSON
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 1:233 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2353
Mailing Address - Country:US
Mailing Address - Phone:909-593-2581
Mailing Address - Fax:909-596-3567
Practice Address - Street 1:233 BASELINE RD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2353
Practice Address - Country:US
Practice Address - Phone:909-593-2581
Practice Address - Fax:909-596-3567
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT34218167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7565AOtherOUTPATIENT MENTAL HEALTH