Provider Demographics
NPI:1548618317
Name:HUERTA, JESSIE
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:HUERTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11780 CENTRAL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-6499
Mailing Address - Country:US
Mailing Address - Phone:909-517-2020
Mailing Address - Fax:909-517-2022
Practice Address - Street 1:2027 E DEODAR ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-1624
Practice Address - Country:US
Practice Address - Phone:909-945-2736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XMedicare UPIN