Basic Information
| Provider Information | |||||||||
| NPI: | 1104150697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORTEZ | ||||||||
| FirstName: | JENNY | ||||||||
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| Credential: | MSW, ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 769 W BLAINE ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925073970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513584705 | ||||||||
| FaxNumber: | 9513584719 | ||||||||
| Practice Location | |||||||||
| Address1: | 769 W BLAINE ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925073970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513584705 | ||||||||
| FaxNumber: | 9513584719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2009 | ||||||||
| LastUpdateDate: | 04/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 104100000X | ASW 30615 | CA | N | Behavioral Health & Social Service Providers | Social Worker | 101YM0800X | 30615 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | LCSW66069 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.