Provider Demographics
NPI:1497164784
Name:TORRES, JAQUELINE
Entity Type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:
Last Name:TORRES
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 1:271 NE 57TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33334-1727
Mailing Address - Country:US
Mailing Address - Phone:305-834-1879
Mailing Address - Fax:
Practice Address - Street 1:10650 WEST ROAD 84 SUITE 206
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324
Practice Address - Country:US
Practice Address - Phone:954-634-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012076000Medicaid