Provider Demographics
NPI:1831661479
Name:MEDINA, JACQUELYNE CISNEROS (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELYNE
Middle Name:CISNEROS
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JACQUELYNE
Other - Middle Name:OLIVIA
Other - Last Name:CISNEROS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:7417 LE CONTE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-7129
Mailing Address - Country:US
Mailing Address - Phone:915-887-3410
Mailing Address - Fax:
Practice Address - Street 1:1551 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5668
Practice Address - Country:US
Practice Address - Phone:915-757-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-20
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX685771041C0700X, 104100000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical