Provider Demographics
NPI:1003497413
Name:VILLALVA, JACQUELINE MONIQUE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MONIQUE
Last Name:VILLALVA
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 1:310 G ST APT 7
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4525
Mailing Address - Country:US
Mailing Address - Phone:619-495-1091
Mailing Address - Fax:
Practice Address - Street 1:5075 SHOREHAM PL STE 115
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5927
Practice Address - Country:US
Practice Address - Phone:858-272-2662
Practice Address - Fax:858-272-2661
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABACB676340106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician