Provider Demographics
NPI:1750717880
Name:DE SANTIAGO, JESSICA LARA (PSYD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LARA
Last Name:DE SANTIAGO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1388
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-0047
Mailing Address - Country:US
Mailing Address - Phone:909-573-3150
Mailing Address - Fax:
Practice Address - Street 1:16465 SIERRA LAKES PKWY STE 140
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1242
Practice Address - Country:US
Practice Address - Phone:909-244-9593
Practice Address - Fax:833-903-0337
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-20
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225C00000X
CA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor