Provider Demographics
NPI:1477068005
Name:REYES, JACOBO MACHUCA (BA, RADT)
Entity Type:Individual
Prefix:
First Name:JACOBO
Middle Name:MACHUCA
Last Name:REYES
Suffix:
Gender:M
Credentials:BA, RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3114 PATRITTI AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3503
Mailing Address - Country:US
Mailing Address - Phone:323-636-1716
Mailing Address - Fax:
Practice Address - Street 1:5825 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4612
Practice Address - Country:US
Practice Address - Phone:323-933-9022
Practice Address - Fax:323-933-4029
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1282711117101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor