Provider Demographics
NPI:1518518539
Name:ELIZALDE, JAZMIN
Entity Type:Individual
Prefix:
First Name:JAZMIN
Middle Name:
Last Name:ELIZALDE
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 1:1145 N WEST ST APT 3
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-2914
Mailing Address - Country:US
Mailing Address - Phone:714-225-3003
Mailing Address - Fax:
Practice Address - Street 1:1145 N WEST ST APT 3
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2914
Practice Address - Country:US
Practice Address - Phone:714-225-3003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty