Provider Demographics
NPI:1821772674
Name:OGUNDUYILE, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:OGUNDUYILE
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 1:1950 S SUNWEST LN STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3248
Mailing Address - Country:US
Mailing Address - Phone:909-252-4017
Mailing Address - Fax:909-252-4055
Practice Address - Street 1:780 E GILBERT ST, SAN BERNADINO
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404
Practice Address - Country:US
Practice Address - Phone:909-387-7194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker