Basic Information
| Provider Information | |||||||||
| NPI: | 1629164991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAREZ | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1841 | ||||||||
| Address2: | 5TH AND WESTERN | ||||||||
| City: | NORCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928600991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517372683 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 23119 COTTONWOOD AVE | ||||||||
| Address2: | BLD A SUITE 110 | ||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925539661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514135678 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 09/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS21363 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.