Provider Demographics
NPI:1497526859
Name:PEREZ, JACQUELYN MARLENE
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MARLENE
Last Name:PEREZ
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 1:21515 HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503
Mailing Address - Country:US
Mailing Address - Phone:424-571-2618
Mailing Address - Fax:
Practice Address - Street 1:5526 LEMON AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-5440
Practice Address - Country:US
Practice Address - Phone:562-728-7150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12046318106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst