Provider Demographics
NPI:1487007977
Name:CHAMPA, JAINEE
Entity Type:Individual
Prefix:
First Name:JAINEE
Middle Name:
Last Name:CHAMPA
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 1:8404 SAN CARLOS WAY
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-2804
Mailing Address - Country:US
Mailing Address - Phone:714-776-6090
Mailing Address - Fax:
Practice Address - Street 1:707 N ANAHEIM BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-2652
Practice Address - Country:US
Practice Address - Phone:714-776-7490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)