Provider Demographics
NPI:1639752702
Name:JAQUEZ, JACQUELINE (QMHS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:JAQUEZ
Suffix:
Gender:F
Credentials:QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2283 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43620-1205
Mailing Address - Country:US
Mailing Address - Phone:419-241-9277
Mailing Address - Fax:
Practice Address - Street 1:915 N ERIE ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-1605
Practice Address - Country:US
Practice Address - Phone:419-776-1757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health