Provider Demographics
NPI:1013615772
Name:DE JESUS, CZARINA PANGILINAN (AMFT)
Entity Type:Individual
Prefix:
First Name:CZARINA
Middle Name:PANGILINAN
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 PAULARINO AVE APT B107
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2905
Mailing Address - Country:US
Mailing Address - Phone:949-258-3801
Mailing Address - Fax:
Practice Address - Street 1:26 CORPORATE PLAZA DR STE 280
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7976
Practice Address - Country:US
Practice Address - Phone:562-553-2403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT127678106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1871723965OtherOUT OF NETWORK, OUTPATIENT PRIVATE GROUP PRACTICE