Provider Demographics
NPI:1245902642
Name:GUTIERREZ, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GUTIERREZ
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 1:3049 JEFFREY DR APT C
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2969
Mailing Address - Country:US
Mailing Address - Phone:714-209-9461
Mailing Address - Fax:
Practice Address - Street 1:1360 S ANAHEIM BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6205
Practice Address - Country:US
Practice Address - Phone:714-209-9461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker