Basic Information
| Provider Information | |||||||||
| NPI: | 1952626558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | MENDOZA | ||||||||
| OtherFirstName: | JEANETTE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2286 ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917681001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 E CHAPMAN AVE | ||||||||
| Address2: | S # 203 | ||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928313839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146808268 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2010 | ||||||||
| LastUpdateDate: | 05/22/2014 | ||||||||
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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 | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.