Provider Demographics
NPI:1558062661
Name:PLAZA, JACQUELINE NINFA
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NINFA
Last Name:PLAZA
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 1:2426 CHAPARAL ST
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:CA
Mailing Address - Zip Code:93662-3252
Mailing Address - Country:US
Mailing Address - Phone:559-375-9557
Mailing Address - Fax:
Practice Address - Street 1:311 E MERCED ST
Practice Address - Street 2:
Practice Address - City:FOWLER
Practice Address - State:CA
Practice Address - Zip Code:93625-2316
Practice Address - Country:US
Practice Address - Phone:559-892-9452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
CAAPCC15016101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician