Basic Information
| Provider Information | |||||||||
| NPI: | 1932569993 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FIELDS | ||||||||
| FirstName: | JARVIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24420 MYERS AVE | ||||||||
| Address2: | 13 | ||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925532855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518091951 | ||||||||
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| Practice Location | |||||||||
| Address1: | 81557 DR CARREON BLVD STE C9 | ||||||||
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| City: | INDIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922015562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603916999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2016 | ||||||||
| LastUpdateDate: | 02/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.