Provider Demographics
NPI:1265999304
Name:VACA, JORGE JR
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:VACA
Suffix:JR
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 1:9140 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-6727
Mailing Address - Country:US
Mailing Address - Phone:818-895-2206
Mailing Address - Fax:818-895-0824
Practice Address - Street 1:9140 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-6727
Practice Address - Country:US
Practice Address - Phone:818-895-2006
Practice Address - Fax:818-895-0824
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)