Provider Demographics
NPI:1851067698
Name:DE HARA, JEANNINE
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:DE HARA
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 1:316 E E ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-3712
Mailing Address - Country:US
Mailing Address - Phone:909-983-4466
Mailing Address - Fax:
Practice Address - Street 1:316 E E ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-3712
Practice Address - Country:US
Practice Address - Phone:909-983-4466
Practice Address - Fax:909-983-1144
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1487916755Medicaid