Provider Demographics
NPI:1639979560
Name:HERNANDEZ, JENNESY
Entity type:Individual
Prefix:
First Name:JENNESY
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13060 OASIS RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-6313
Mailing Address - Country:US
Mailing Address - Phone:760-909-7532
Mailing Address - Fax:
Practice Address - Street 1:930 S MOUNT VERNON AVE STE 90
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3928
Practice Address - Country:US
Practice Address - Phone:909-252-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-22-245749106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician