Provider Demographics
NPI:1962671800
Name:DUQUE, JORGE A
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:A
Last Name:DUQUE
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:PO BOX 962
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95061-0962
Mailing Address - Country:US
Mailing Address - Phone:831-454-4170
Mailing Address - Fax:831-454-4663
Practice Address - Street 1:1080 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1966
Practice Address - Country:US
Practice Address - Phone:831-454-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA657261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ91892ZOtherMEDICARE SITE GROUP PTAN# SANTA CRUZ COUNTY CA
CAZZZ92069ZOtherMEDICARE SITE GROUP PTAN# SANTA CRUZ COUNTY CA
CAZZZ91891ZOtherMEDICARE SITE GROUP PTAN# SANTA CRUZ COUNTY CA