Provider Demographics
NPI:1790304970
Name:CALDERON, JAIME RAFAEL
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:RAFAEL
Last Name:CALDERON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 FERMOORE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-2303
Mailing Address - Country:US
Mailing Address - Phone:818-415-1813
Mailing Address - Fax:
Practice Address - Street 1:15339 SATICOY ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3345
Practice Address - Country:US
Practice Address - Phone:818-497-1285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator