Provider Demographics
NPI:1912539396
Name:GUTIERREZ, JORGE ANDREW
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:ANDREW
Last Name:GUTIERREZ
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 1:1260 E ARROW HWY BLDG E
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4984
Mailing Address - Country:US
Mailing Address - Phone:909-932-1069
Mailing Address - Fax:
Practice Address - Street 1:1260 E ARROW HWY BLDG E
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4984
Practice Address - Country:US
Practice Address - Phone:909-932-1069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1348550519101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)