Basic Information
| Provider Information | |||||||||
| NPI: | 1275821175 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SECUYA | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | DANIELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2940 INLAND EMPIRE BLVD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917644898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094581350 | ||||||||
| FaxNumber: | 9092524055 | ||||||||
| Practice Location | |||||||||
| Address1: | 2940 INLAND EMPIRE BLVD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917644898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094581350 | ||||||||
| FaxNumber: | 9095798149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2011 | ||||||||
| LastUpdateDate: | 06/04/2015 | ||||||||
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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 | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.