Provider Demographics
NPI:1700336732
Name:IBARRA, JERRY (CATC IV)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:IBARRA
Suffix:
Gender:M
Credentials:CATC IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9331 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-6374
Mailing Address - Country:US
Mailing Address - Phone:714-319-8078
Mailing Address - Fax:
Practice Address - Street 1:9331 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-6374
Practice Address - Country:US
Practice Address - Phone:714-319-8078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA156156101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)