Basic Information
| Provider Information | |||||||||
| NPI: | 1629090592 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEWCOMER | ||||||||
| FirstName: | JEANNE | ||||||||
| MiddleName: | PATRICIA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8180 SVL BOX | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923955122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609530429 | ||||||||
| FaxNumber: | 7609518986 | ||||||||
| Practice Location | |||||||||
| Address1: | 15447 ANACAPA RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923922481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602459446 | ||||||||
| FaxNumber: | 7609518986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS6200 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6681536 | 05 | CA | MEDICAID |