Provider Demographics
NPI:1134644115
Name:VASQUEZ, JORGE (CADC-I)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:CADC-I
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 1221
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-1221
Mailing Address - Country:US
Mailing Address - Phone:949-478-3849
Mailing Address - Fax:
Practice Address - Street 1:222 W HOSPITALITY LN
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-3536
Practice Address - Country:US
Practice Address - Phone:909-421-4601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CACICA01850919101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty