Provider Demographics
NPI:1508380643
Name:VALLEJO, JORGE (BA)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:VALLEJO
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 VILLA MANUCHA RD
Mailing Address - Street 2:
Mailing Address - City:NEWMAN
Mailing Address - State:CA
Mailing Address - Zip Code:95360-9749
Mailing Address - Country:US
Mailing Address - Phone:209-996-9748
Mailing Address - Fax:
Practice Address - Street 1:330 VILLA MANUCHA RD
Practice Address - Street 2:
Practice Address - City:NEWMAN
Practice Address - State:CA
Practice Address - Zip Code:95360-9749
Practice Address - Country:US
Practice Address - Phone:209-996-9748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator