Provider Demographics
NPI:1639520661
Name:CARRASCO, JACQUELINE (MSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:CARRASCO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:S
Other - Last Name:CARRASCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:550 SOUTH VERMONT AVE
Mailing Address - Street 2:10TH FLOOR
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020
Mailing Address - Country:US
Mailing Address - Phone:213-996-1347
Mailing Address - Fax:
Practice Address - Street 1:550 SOUTH VERMONT AVE
Practice Address - Street 2:10TH FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020
Practice Address - Country:US
Practice Address - Phone:213-996-1347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA972331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD2192997OtherDRIVER'S LICENSE