Provider Demographics
NPI:1932676772
Name:PALACIOS, JORGE LUIS
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:PALACIOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4645 ARLINGTON AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-2765
Mailing Address - Country:US
Mailing Address - Phone:951-264-1814
Mailing Address - Fax:
Practice Address - Street 1:1288 N VERDUGO RD STE A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-6304
Practice Address - Country:US
Practice Address - Phone:951-264-1814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician