Provider Demographics
NPI:1578810305
Name:ANAYA, JACQUELINE JAG (LAC)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:JAG
Last Name:ANAYA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1264 HIGUERA STREET, SUITE 102
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401
Mailing Address - Country:US
Mailing Address - Phone:805-203-3014
Mailing Address - Fax:
Practice Address - Street 1:1264 HIGUERA STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-203-3014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14504171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist