Provider Demographics
NPI:1700411576
Name:REYES, JAQUELINA ANDREA
Entity Type:Individual
Prefix:
First Name:JAQUELINA
Middle Name:ANDREA
Last Name:REYES
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 1:25279 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-2468
Mailing Address - Country:US
Mailing Address - Phone:310-985-9501
Mailing Address - Fax:602-455-4624
Practice Address - Street 1:25279 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-2468
Practice Address - Country:US
Practice Address - Phone:310-985-9501
Practice Address - Fax:602-455-4624
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2656335385HR2055X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child