Provider Demographics
NPI:1720392152
Name:HEIM, JENNIFER KACHELEK
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:KACHELEK
Last Name:HEIM
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:KACHELEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:850 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-5230
Mailing Address - Country:US
Mailing Address - Phone:909-580-2141
Mailing Address - Fax:909-580-2866
Practice Address - Street 1:850 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5230
Practice Address - Country:US
Practice Address - Phone:909-580-2141
Practice Address - Fax:909-580-2866
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA682521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical