Provider Demographics
NPI:1033556469
Name:BAUTISTA, JACQUELINE (MS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SAN LEANDRO BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-1675
Mailing Address - Country:US
Mailing Address - Phone:510-293-7048
Mailing Address - Fax:510-293-7124
Practice Address - Street 1:1000 SAN LEANDRO BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-1675
Practice Address - Country:US
Practice Address - Phone:510-293-7048
Practice Address - Fax:510-293-7124
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health