Provider Demographics
NPI:1235655176
Name:VILLICANA, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:VILLICANA
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 1:311 E MERCED ST
Mailing Address - Street 2:
Mailing Address - City:FOWLER
Mailing Address - State:CA
Mailing Address - Zip Code:93625-2316
Mailing Address - Country:US
Mailing Address - Phone:559-892-9452
Mailing Address - Fax:
Practice Address - Street 1:311 E MERCED ST
Practice Address - Street 2:
Practice Address - City:FOWLER
Practice Address - State:CA
Practice Address - Zip Code:93625-2316
Practice Address - Country:US
Practice Address - Phone:559-892-9452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17017101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)