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General NPI Number Information
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NPI Number | 1265069355
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Entity Type | Organization
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Legal Business Name | PROTOTYPES
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Dates
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Enumeration Date | 03/26/2020
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Last Update Date | 03/27/2020
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Provider Practice Location Address
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Address Line | 831 E ARROW HWY
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City | POMONA
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State | CA
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Zip | 91767-2535
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Country | US
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Telephone | 909-624-1233
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Fax |
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Provider Business Mailing Address
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Address Line | 831 E ARROW HWY
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City | POMONA
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State | CA
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Zip | 91767-2535
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Country | US
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Telephone | 909-624-1233
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Fax |
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Authorized Official
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Title or Position | SUD COUNSELOR II
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Name | EVANNE BREE JACKSON
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Credential |
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Telephone | 909-624-1233
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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