Provider Demographics
NPI:1598426660
Name:MENDEZ, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MENDEZ
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 1:4330 W 106TH ST APT A
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90304-2035
Mailing Address - Country:US
Mailing Address - Phone:424-385-7880
Mailing Address - Fax:
Practice Address - Street 1:10000 W PICO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-3417
Practice Address - Country:US
Practice Address - Phone:424-385-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-31
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70242225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist