Provider Demographics
NPI:1336474857
Name:FITTS, JACQUELINE R
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:R
Last Name:FITTS
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 1:1076 SANTO ANTONIO DR STE B
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-8183
Mailing Address - Country:US
Mailing Address - Phone:909-433-9824
Mailing Address - Fax:909-433-9830
Practice Address - Street 1:1076 SANTO ANTONIO DR STE B
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-8183
Practice Address - Country:US
Practice Address - Phone:909-433-9824
Practice Address - Fax:909-433-9830
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARS3285101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)