Provider Demographics
NPI:1891395232
Name:RIOS, JACQULYN DANIELLE
Entity Type:Individual
Prefix:
First Name:JACQULYN
Middle Name:DANIELLE
Last Name:RIOS
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 1:4604 W DOUGLAS AVE APT 103
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4195
Mailing Address - Country:US
Mailing Address - Phone:559-909-7430
Mailing Address - Fax:
Practice Address - Street 1:4604 W DOUGLAS AVE APT 103
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4195
Practice Address - Country:US
Practice Address - Phone:559-909-7430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90589009EMedicaid