Provider Demographics
NPI:1609055755
Name:VARGAS, JEANET
Entity Type:Individual
Prefix:
First Name:JEANET
Middle Name:
Last Name:VARGAS
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 1:2114 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-4831
Mailing Address - Country:US
Mailing Address - Phone:310-940-2140
Mailing Address - Fax:
Practice Address - Street 1:240 E 20TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-5418
Practice Address - Country:US
Practice Address - Phone:562-218-4095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW626131041C0700X
171M00000X
CA888061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAASW62613OtherACSW