Basic Information
| Provider Information | |||||||||
| NPI: | 1851751622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YNIGUEZ | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANNIE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | CADC-CAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12426 WHITTIER BLVD | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906021017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629447953 | ||||||||
| FaxNumber: | 5629467494 | ||||||||
| Practice Location | |||||||||
| Address1: | 10511 MILLS AVE | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906041017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629447953 | ||||||||
| FaxNumber: | 5629467494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2016 | ||||||||
| LastUpdateDate: | 03/07/2016 | ||||||||
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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 | 324500000X | C23261214 | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | C23261214 | 01 | CA | CCAPP CREDENTIALING | OTHER |