Provider Demographics
NPI:1790324143
Name:PEREZ, JESSE WILLIAM
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:WILLIAM
Last Name:PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40687 DUTTON ST
Mailing Address - Street 2:
Mailing Address - City:CHERRY VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92223-4533
Mailing Address - Country:US
Mailing Address - Phone:909-543-7879
Mailing Address - Fax:
Practice Address - Street 1:40687 DUTTON ST
Practice Address - Street 2:
Practice Address - City:CHERRY VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92223-4533
Practice Address - Country:US
Practice Address - Phone:909-543-7879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician