Provider Demographics
NPI:1316216237
Name:CAMARENA, JACKIE (MFT TRAINEE)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:CAMARENA
Suffix:
Gender:F
Credentials:MFT TRAINEE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1862 INDIANAPOLIS AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-5262
Mailing Address - Country:US
Mailing Address - Phone:559-248-8550
Mailing Address - Fax:559-248-8555
Practice Address - Street 1:5168 N BLYTHE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-6477
Practice Address - Country:US
Practice Address - Phone:559-248-8550
Practice Address - Fax:559-248-8555
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health