Basic Information
| Provider Information | |||||||||
| NPI: | 1710400452 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAVEZ | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | BERNISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14677 MERRILL AVE | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923354219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516432340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2275 S MAIN ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928825303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512793222 | ||||||||
| FaxNumber: | 9512795222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2017 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041C0700X | 91659 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.