Basic Information
| Provider Information | |||||||||
| NPI: | 1942641824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LA TORRE | ||||||||
| FirstName: | JESSICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12017 ODESSA DR | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925577839 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3801 UNIVERSITY AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925013247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519557108 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2013 | ||||||||
| LastUpdateDate: | 07/08/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.