Provider Demographics
NPI:1073184511
Name:MANJARREZ, JACOB ALEXANDER
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ALEXANDER
Last Name:MANJARREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15111 FREEMAN AVE UNIT 73
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-2154
Mailing Address - Country:US
Mailing Address - Phone:310-920-8411
Mailing Address - Fax:
Practice Address - Street 1:25101 THE OLD RD STE 142A
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91381-2206
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician