Provider Demographics
NPI:1679051890
Name:WILLIS, JERMAINE L
Entity type:Individual
Prefix:
First Name:JERMAINE
Middle Name:L
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9592 7TH ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5609
Mailing Address - Country:US
Mailing Address - Phone:951-376-0354
Mailing Address - Fax:
Practice Address - Street 1:225 W HOSPITALITY LN STE 201H
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3245
Practice Address - Country:US
Practice Address - Phone:951-446-7417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst