Provider Demographics
NPI:1700499415
Name:MADRID, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:MADRID
Suffix:
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 1:255 E RINCON ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-1367
Mailing Address - Country:US
Mailing Address - Phone:951-817-5328
Mailing Address - Fax:
Practice Address - Street 1:52085 AVENIDA NAVARRO
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-5234
Practice Address - Country:US
Practice Address - Phone:760-391-3707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician