Provider Demographics
NPI:1083263271
Name:QUITADAMO, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:QUITADAMO
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:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48143-0663
Mailing Address - Country:US
Mailing Address - Phone:810-559-2129
Mailing Address - Fax:
Practice Address - Street 1:10795 ACACIA LN
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-1811
Practice Address - Country:US
Practice Address - Phone:818-903-8258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician