Provider Demographics
NPI:1073844148
Name:PEREZ, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PEREZ
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 1:14023 LEFLOSS AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-3523
Mailing Address - Country:US
Mailing Address - Phone:562-219-1789
Mailing Address - Fax:
Practice Address - Street 1:11721 TELEGRAPH RD
Practice Address - Street 2:BLDG. A
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3674
Practice Address - Country:US
Practice Address - Phone:562-949-8455
Practice Address - Fax:562-949-4807
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-28
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health