1003221565 NPI number — MISS JESSICA ESTRADA RECOVERY WORKER

Table of content: MISS JESSICA ESTRADA RECOVERY WORKER (NPI 1003221565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003221565 NPI number — MISS JESSICA ESTRADA RECOVERY WORKER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ESTRADA
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
RECOVERY WORKER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ESTRADA
Provider Other First Name:
JESSICA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RECOVERY WORKER
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1003221565
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2275 EAST COOLEY DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-370-1777
Provider Business Mailing Address Fax Number:
909-370-1776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2275 E COOLEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92324-6324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-370-1777
Provider Business Practice Location Address Fax Number:
909-370-1776
Provider Enumeration Date:
06/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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