Basic Information
| Provider Information | |||||||||
| NPI: | 1679939383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANCHEZ | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | PULIDO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CADDESO411260827 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANCHEZ | ||||||||
| OtherFirstName: | JORGE | ||||||||
| OtherMiddleName: | PULIDO | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 210 STANFORD ST | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950763268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8318403060 | ||||||||
| FaxNumber: | 8314236657 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 RIGG ST | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950604203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314233890 | ||||||||
| FaxNumber: | 8314236657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2016 | ||||||||
| LastUpdateDate: | 01/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CADDESO411260827 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 10 | 01 | CA | MEDICAL | OTHER |