Provider Demographics
NPI:1033987458
Name:LARA, JESSICA VICTORIA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:VICTORIA
Last Name:LARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 GLADE AVE
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-8629
Mailing Address - Country:US
Mailing Address - Phone:559-598-1104
Mailing Address - Fax:
Practice Address - Street 1:4411 N CEDAR AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-2538
Practice Address - Country:US
Practice Address - Phone:559-248-1548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)