Provider Demographics
NPI:1861860009
Name:ARELLANO-JACKSON, RAQUEL MARIE
Entity Type:Individual
Prefix:MS
First Name:RAQUEL
Middle Name:MARIE
Last Name:ARELLANO-JACKSON
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 1:1461 E COOLEY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3921
Mailing Address - Country:US
Mailing Address - Phone:909-904-9757
Mailing Address - Fax:
Practice Address - Street 1:1461 E COOLEY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324
Practice Address - Country:US
Practice Address - Phone:909-904-9757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW68536101YM0800X
CA841931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health