Provider Demographics
NPI:1891415048
Name:SUCCOR PSYCHIATRY & WELLNESS
Entity Type:Organization
Organization Name:SUCCOR PSYCHIATRY & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LAKESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MSN-ED, PMHNP-BC
Authorized Official - Phone:909-648-2036
Mailing Address - Street 1:400 RAMONA AVE STE 212L
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-1443
Mailing Address - Country:US
Mailing Address - Phone:909-648-2036
Mailing Address - Fax:
Practice Address - Street 1:400 RAMONA AVE STE 212L
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1443
Practice Address - Country:US
Practice Address - Phone:909-648-2036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELITE NURSING PROFESSIONALS INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty