Provider Demographics
NPI:1063115814
Name:GLORIA, JEANINE JESSICA (AMFT, APCC)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:JESSICA
Last Name:GLORIA
Suffix:
Gender:F
Credentials:AMFT, APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1084 RAVEN CT
Mailing Address - Street 2:
Mailing Address - City:CALIMESA
Mailing Address - State:CA
Mailing Address - Zip Code:92320-4921
Mailing Address - Country:US
Mailing Address - Phone:909-936-7565
Mailing Address - Fax:
Practice Address - Street 1:1850 N RIVERSIDE AVE STE 180
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-8071
Practice Address - Country:US
Practice Address - Phone:909-379-4406
Practice Address - Fax:909-440-5138
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132476106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist