Provider Demographics
NPI:1275277600
Name:MEJIA, JERALD AUSTIN
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:AUSTIN
Last Name:MEJIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 CONCOURS ST
Mailing Address - Street 2:SUITE 4102
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-6564
Mailing Address - Country:US
Mailing Address - Phone:909-240-1764
Mailing Address - Fax:
Practice Address - Street 1:5080 SPECTRUM DR
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-4648
Practice Address - Country:US
Practice Address - Phone:844-676-9374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician