Provider Demographics
NPI:1073106969
Name:JACOBO, GUADALUPE JOHANNA
Entity Type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:JOHANNA
Last Name:JACOBO
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 1:4388 KATELLA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3565
Mailing Address - Country:US
Mailing Address - Phone:562-596-0050
Mailing Address - Fax:562-596-0058
Practice Address - Street 1:4388 KATELLA AVE
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3565
Practice Address - Country:US
Practice Address - Phone:562-596-0050
Practice Address - Fax:562-596-0058
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)