Provider Demographics
NPI:1033239793
Name:EDWARDS, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:EDWARDS
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 1:1061 PARK AVE
Mailing Address - Street 2:UNIT 115
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-4332
Mailing Address - Country:US
Mailing Address - Phone:562-439-2390
Mailing Address - Fax:
Practice Address - Street 1:456 ELM AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-2426
Practice Address - Country:US
Practice Address - Phone:562-437-6717
Practice Address - Fax:562-437-5072
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator