Basic Information
| Provider Information | |||||||||
| NPI: | 1346524410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUNIPER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | STEPHEN | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1812 W PARK AVE | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923738014 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1812 W PARK AVE | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923738014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097480259 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2011 | ||||||||
| LastUpdateDate: | 07/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YS0200X | PPS 120001848 | CA | N | Behavioral Health & Social Service Providers | Counselor | School | 101YP2500X | PCI 18 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 101YA0400X | 01 | CA | MEDI-CAL | OTHER |