Provider Demographics
NPI:1104043819
Name:BRAVO, JACQUELINE CUELLAR (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:CUELLAR
Last Name:BRAVO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 ST PAUL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-2038
Mailing Address - Country:US
Mailing Address - Phone:213-482-6400
Mailing Address - Fax:
Practice Address - Street 1:600 ST PAUL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-2038
Practice Address - Country:US
Practice Address - Phone:213-482-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26898104100000X
CA701551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker