Provider Demographics
NPI:1851915748
Name:JACQUEZ, EUGENE N/A (PSYD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:N/A
Last Name:JACQUEZ
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 E HILL ST UNIT 105
Mailing Address - Street 2:
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-3761
Mailing Address - Country:US
Mailing Address - Phone:303-908-0213
Mailing Address - Fax:
Practice Address - Street 1:2120 E HILL ST UNIT 105
Practice Address - Street 2:
Practice Address - City:SIGNAL HILL
Practice Address - State:CA
Practice Address - Zip Code:90755-3761
Practice Address - Country:US
Practice Address - Phone:303-908-0213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TS0200X
CA200019205103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool