Provider Demographics
NPI:1639881691
Name:CUQUEJO, JAILENE GABRIELLA
Entity Type:Individual
Prefix:
First Name:JAILENE
Middle Name:GABRIELLA
Last Name:CUQUEJO
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 1:4538 MILL GROVE TER
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-4196
Mailing Address - Country:US
Mailing Address - Phone:404-860-3621
Mailing Address - Fax:
Practice Address - Street 1:4538 MILL GROVE TER
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-4196
Practice Address - Country:US
Practice Address - Phone:404-860-3621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician