Provider Demographics
NPI:1912770223
Name:BAZUA MUNOZ, JAYLEEN
Entity Type:Individual
Prefix:
First Name:JAYLEEN
Middle Name:
Last Name:BAZUA MUNOZ
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 1:15407 BARONA CT
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4121
Mailing Address - Country:US
Mailing Address - Phone:951-464-7793
Mailing Address - Fax:
Practice Address - Street 1:4160 TEMESCAL CANYON RD STE 309
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92883-4629
Practice Address - Country:US
Practice Address - Phone:949-478-0235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142424106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist