Provider Demographics
NPI:1841169794
Name:MEDINA, JAYLENE RAE
Entity type:Individual
Prefix:
First Name:JAYLENE
Middle Name:RAE
Last Name:MEDINA
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 1:5021 W AVENUE L14 APT 8
Mailing Address - Street 2:
Mailing Address - City:QUARTZ HILL
Mailing Address - State:CA
Mailing Address - Zip Code:93536-3688
Mailing Address - Country:US
Mailing Address - Phone:661-643-0644
Mailing Address - Fax:
Practice Address - Street 1:16600 SHERMAN WAY STE 178
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3875
Practice Address - Country:US
Practice Address - Phone:818-235-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-30
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician