Provider Demographics
NPI:1528604048
Name:VAZQUEZ, JALIL
Entity Type:Individual
Prefix:
First Name:JALIL
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 E 4TH ST STE 107
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3818
Mailing Address - Country:US
Mailing Address - Phone:714-543-5437
Mailing Address - Fax:
Practice Address - Street 1:2130 E 4TH ST STE 107
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3818
Practice Address - Country:US
Practice Address - Phone:714-543-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X, 106H00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No175T00000XOther Service ProvidersPeer Specialist