Provider Demographics
NPI:1912770223
Name:BAZUA MUNOZ, JAYLEEN
Entity type:Individual
Prefix:
First Name:JAYLEEN
Middle Name:
Last Name:BAZUA MUNOZ
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 1:1419 GIOSETTA ST
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-8310
Mailing Address - Country:US
Mailing Address - Phone:951-464-7793
Mailing Address - Fax:
Practice Address - Street 1:3400 CENTRAL AVE STE 310
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2181
Practice Address - Country:US
Practice Address - Phone:951-465-4996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2025-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142424106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist