Provider Demographics
NPI:1962000984
Name:JASMIN, MYLENE GRACE VILLANUEVA
Entity type:Individual
Prefix:
First Name:MYLENE GRACE
Middle Name:VILLANUEVA
Last Name:JASMIN
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 1:13630 FOSTER AVE APT 34
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-4846
Mailing Address - Country:US
Mailing Address - Phone:626-869-8525
Mailing Address - Fax:
Practice Address - Street 1:851 S SUNSET AVE APT 98
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-5542
Practice Address - Country:US
Practice Address - Phone:626-869-8525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA151192106H00000X
CA120427106H00000X
CAAMFT120427101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7708OtherMEDICAL
CA7184OtherMEDICAL
CA7368OtherMEDICAL
CA7667OtherMEDICAL