Provider Demographics
NPI:1811028871
Name:RIVERA, JACQUELYN LEE (LCSW, PPSC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:LEE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LCSW, PPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 E. 4TH ST.
Mailing Address - Street 2:#204
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705
Mailing Address - Country:US
Mailing Address - Phone:714-547-0885
Mailing Address - Fax:714-547-8352
Practice Address - Street 1:111 N LA BREA AVE STE 700
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4651
Practice Address - Country:US
Practice Address - Phone:310-677-7808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374700000X
CALCS271131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No374700000XNursing Service Related ProvidersTechnician