Provider Demographics
NPI:1780396689
Name:ESCOBAR, MANUEL DE JESUS JR
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:DE JESUS
Last Name:ESCOBAR
Suffix:JR
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 1:1790 MIRAMAR ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3424
Mailing Address - Country:US
Mailing Address - Phone:323-613-5793
Mailing Address - Fax:
Practice Address - Street 1:1790 MIRAMAR ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3424
Practice Address - Country:US
Practice Address - Phone:323-613-5793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101200000X, 101Y00000X, 101YM0800X, 102L00000X, 103K00000X, 103TA0400X, 103TC1900X, 101YA0400X
CA101YP2500X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101200000XBehavioral Health & Social Service ProvidersDrama Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling