Provider Demographics
NPI:1619646486
Name:VICTORY, JOHN EDWARD JR
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:VICTORY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S SANTA ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-3536
Mailing Address - Country:US
Mailing Address - Phone:626-753-5379
Mailing Address - Fax:
Practice Address - Street 1:572 N ARROWHEAD AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1251
Practice Address - Country:US
Practice Address - Phone:626-753-5379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor