Provider Demographics
NPI:1588377014
Name:CHASCO-ORTEGA, LESLIE JECCETT
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:JECCETT
Last Name:CHASCO-ORTEGA
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 1:11224 DEVINE CIR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5896
Mailing Address - Country:US
Mailing Address - Phone:909-697-0870
Mailing Address - Fax:
Practice Address - Street 1:11224 DEVINE CIR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5896
Practice Address - Country:US
Practice Address - Phone:909-697-0870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY4339187106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20060500420700OtherIEHP