Provider Demographics
NPI:1689256166
Name:LIZARRAGA, JAQUELINE
Entity Type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:
Last Name:LIZARRAGA
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 1:16801 N 31ST ST APT 102
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2644
Mailing Address - Country:US
Mailing Address - Phone:602-413-9889
Mailing Address - Fax:
Practice Address - Street 1:4617 E BELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2305
Practice Address - Country:US
Practice Address - Phone:602-482-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-24
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZT067223183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD10948148OtherPASSPORT