Basic Information
| Provider Information | |||||||||
| NPI: | 1629541511 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JESTER | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6161 DARCEE DR | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925096273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512614220 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4295 BROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925013446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516836596 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2019 | ||||||||
| LastUpdateDate: | 01/03/2019 | ||||||||
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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 | 101YA0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.