Healthcare Provider Details

I. General information

NPI: 1033987458
Provider Name (Legal Business Name): JESSICA VICTORIA LARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2023
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 N CEDAR AVE
FRESNO CA
93726-2538
US

IV. Provider business mailing address

2937 GLADE AVE
MADERA CA
93637-8629
US

V. Phone/Fax

Practice location:
  • Phone: 559-248-1548
  • Fax:
Mailing address:
  • Phone: 559-598-1104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: