Provider Demographics
NPI:1750982534
Name:GOMEZ, JAYLENE ALICIA
Entity type:Individual
Prefix:
First Name:JAYLENE
Middle Name:ALICIA
Last Name:GOMEZ
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 1:1737 ATLANTA AVE STE H8
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2419
Mailing Address - Country:US
Mailing Address - Phone:951-248-4873
Mailing Address - Fax:
Practice Address - Street 1:1737 ATLANTA AVE STE H8
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2419
Practice Address - Country:US
Practice Address - Phone:951-248-4873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2022-08-19
Deactivation Date:2022-05-03
Deactivation Code:
Reactivation Date:2022-07-26
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator