Healthcare Provider Details

I. General information

NPI: 1750717880
Provider Name (Legal Business Name): JESSICA LARA DE SANTIAGO PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2013
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16465 SIERRA LAKES PKWY STE 140
FONTANA CA
92336-1242
US

IV. Provider business mailing address

PO BOX 1388
CHINO HILLS CA
91709-0047
US

V. Phone/Fax

Practice location:
  • Phone: 909-244-9593
  • Fax: 833-903-0337
Mailing address:
  • Phone: 909-573-3150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: