Provider Demographics
NPI:1992553812
Name:MEDINA, JERELLE YSOBEL TOBIAS
Entity type:Individual
Prefix:
First Name:JERELLE
Middle Name:YSOBEL TOBIAS
Last Name:MEDINA
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 1:13831 PORTOFINO ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-3855
Mailing Address - Country:US
Mailing Address - Phone:909-689-6634
Mailing Address - Fax:
Practice Address - Street 1:2650 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3439
Practice Address - Country:US
Practice Address - Phone:626-577-2163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program