Provider Demographics
NPI:1558877258
Name:CANIDA, JEANETTE
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:CANIDA
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 1:29605 SOLANA WAY APT H2
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-5712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3602 INLAND EMPIRE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4900
Practice Address - Country:US
Practice Address - Phone:909-476-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician