Provider Demographics
NPI:1962255752
Name:YAGHOUBIAN, JENNIFER LYNN (PPS)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNN
Last Name:YAGHOUBIAN
Suffix:
Gender:F
Credentials:PPS
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:CROFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 W LUGONIA AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-2234
Mailing Address - Country:US
Mailing Address - Phone:909-800-4679
Mailing Address - Fax:
Practice Address - Street 1:1320 CRAFTON AVE
Practice Address - Street 2:
Practice Address - City:MENTONE
Practice Address - State:CA
Practice Address - Zip Code:92359-1318
Practice Address - Country:US
Practice Address - Phone:909-800-4679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA200065241101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool