Provider Demographics
NPI:1467210385
Name:VICENTE, JASMIN
Entity Type:Individual
Prefix:
First Name:JASMIN
Middle Name:
Last Name:VICENTE
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 1:1112 E 71ST ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-1026
Mailing Address - Country:US
Mailing Address - Phone:562-513-2124
Mailing Address - Fax:
Practice Address - Street 1:1112 E 71ST ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-1026
Practice Address - Country:US
Practice Address - Phone:562-413-2124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY4726722106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician