Provider Demographics
NPI:1104473131
Name:ORTIZ, JEANICE MAUREEN
Entity type:Individual
Prefix:
First Name:JEANICE
Middle Name:MAUREEN
Last Name:ORTIZ
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 1:340 RANCHEROS DR STE 166
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-2980
Mailing Address - Country:US
Mailing Address - Phone:760-744-3672
Mailing Address - Fax:
Practice Address - Street 1:340 RANCHEROS DR STE 166
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2980
Practice Address - Country:US
Practice Address - Phone:760-744-3672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist