Provider Demographics
NPI:1265069355
Name:PROTOTYPES
Entity type:Organization
Organization Name:PROTOTYPES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUD COUNSELOR II
Authorized Official - Prefix:
Authorized Official - First Name:EVANNE
Authorized Official - Middle Name:BREE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-624-1233
Mailing Address - Street 1:831 E ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2535
Mailing Address - Country:US
Mailing Address - Phone:909-624-1233
Mailing Address - Fax:
Practice Address - Street 1:831 E ARROW HWY
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2535
Practice Address - Country:US
Practice Address - Phone:909-624-1233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-26
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty