Provider Demographics
NPI:1295369684
Name:JA'QUEZ, LORENE (LISAC)
Entity Type:Individual
Prefix:
First Name:LORENE
Middle Name:
Last Name:JA'QUEZ
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:LORENE
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4825 N SABINO CANYON RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-6427
Mailing Address - Country:US
Mailing Address - Phone:520-495-6206
Mailing Address - Fax:520-884-0383
Practice Address - Street 1:4825 N SABINO CANYON RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85750-6427
Practice Address - Country:US
Practice Address - Phone:520-495-6206
Practice Address - Fax:520-884-0383
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10072101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLISAC-10072OtherAZ BOARD OF BEHAVIORAL HEALTH EXAMINERS LICENSE LISAC