Provider Demographics
NPI:1790402584
Name:ZELADA, JACQUELINE R
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:ZELADA
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 1:11682 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3832
Mailing Address - Country:US
Mailing Address - Phone:310-537-5883
Mailing Address - Fax:
Practice Address - Street 1:11682 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3832
Practice Address - Country:US
Practice Address - Phone:310-537-5883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1476060722101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor