Basic Information
| Provider Information | |||||||||
| NPI: | 1407121999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BECERRA | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | ARTURO | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4424 SO. CENTINELA AVE. 102 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104873536 | ||||||||
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| Practice Location | |||||||||
| Address1: | 790 E. BONITA | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262545000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2012 | ||||||||
| LastUpdateDate: | 08/30/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 01-109311 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 01-109311 | 01 | CA | SUBSTANCE ABUSE COUNSELOR CAS | OTHER |