Provider Demographics
NPI:1912871583
Name:FALLENTINE, JORDAN REBEKAH (PMHNP)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:REBEKAH
Last Name:FALLENTINE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30810 SOUTHEND LN
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-6340
Mailing Address - Country:US
Mailing Address - Phone:951-704-6975
Mailing Address - Fax:
Practice Address - Street 1:30810 SOUTHEND LN
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:CA
Practice Address - Zip Code:92596-6340
Practice Address - Country:US
Practice Address - Phone:951-704-6975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95184578363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty