Basic Information
| Provider Information | |||||||||
| NPI: | 1487130050 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1907 BOYS REPUBLIC DR | ||||||||
| Address2: | |||||||||
| City: | CHINO HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917095447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096281217 | ||||||||
| FaxNumber: | 9093065427 | ||||||||
| Practice Location | |||||||||
| Address1: | 1815 REDCLIFF ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900261133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236616905 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2018 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 10482 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 10482 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 95-2633765 | 01 | CA | MEDICAL | OTHER |