Provider Demographics
NPI:1871390336
Name:OCONNELL, AUTUMN JEAN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:JEAN
Last Name:OCONNELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 PINE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-7153
Mailing Address - Country:US
Mailing Address - Phone:951-330-0196
Mailing Address - Fax:
Practice Address - Street 1:34448 YUCAIPA BLVD STE A
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2412
Practice Address - Country:US
Practice Address - Phone:909-353-7547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician