Provider Demographics
NPI:1184190761
Name:MARTINEZ, JACQUELINE MORALES
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MORALES
Last Name:MARTINEZ
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 1:378 ASTORIA DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78220-1602
Mailing Address - Country:US
Mailing Address - Phone:512-748-0990
Mailing Address - Fax:
Practice Address - Street 1:3 BUTTERFIELD TRAIL BLVD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79906-4951
Practice Address - Country:US
Practice Address - Phone:800-991-6070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-15-08997106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician