Provider Demographics
NPI:1053299594
Name:SALCEDO, JOSE REVELES (PMHNP)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:REVELES
Last Name:SALCEDO
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15071 LIME ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-3816
Mailing Address - Country:US
Mailing Address - Phone:909-921-8953
Mailing Address - Fax:
Practice Address - Street 1:16888 NISQUALLI RD STE 200-4
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-9703
Practice Address - Country:US
Practice Address - Phone:909-921-8953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-22
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95036807363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health