Provider Demographics
NPI:1811617053
Name:MEDINA, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6475 LORENA AVE
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91752-2532
Mailing Address - Country:US
Mailing Address - Phone:626-513-3365
Mailing Address - Fax:
Practice Address - Street 1:2813 S MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-5942
Practice Address - Country:US
Practice Address - Phone:951-737-2962
Practice Address - Fax:951-737-2783
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 175T00000X
CAMPSS-SWKMTV175T00000X
CAR1523970923101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist