Provider Demographics
NPI:1366167967
Name:HEFNER, JEANETTE MARIE
Entity type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:MARIE
Last Name:HEFNER
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JEANETTE
Other - Middle Name:MARIE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:24694 BAY AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-3809
Mailing Address - Country:US
Mailing Address - Phone:951-288-5735
Mailing Address - Fax:
Practice Address - Street 1:15740 TURNBERRY ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4903
Practice Address - Country:US
Practice Address - Phone:951-214-3675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
172V00000X, 373H00000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA6071953Medicaid