Provider Demographics
NPI:1376962308
Name:RUEDA, JACKELIN CHAVEZ
Entity Type:Individual
Prefix:
First Name:JACKELIN
Middle Name:CHAVEZ
Last Name:RUEDA
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:P.O. BOX 6779
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206
Mailing Address - Country:US
Mailing Address - Phone:209-368-2532
Mailing Address - Fax:209-625-0492
Practice Address - Street 1:1920 TIENDA DR. #101
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242
Practice Address - Country:US
Practice Address - Phone:209-647-0398
Practice Address - Fax:209-625-0492
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor