Provider Demographics
NPI:1295302172
Name:VARGAS CORRALES, JACKELYNE
Entity type:Individual
Prefix:
First Name:JACKELYNE
Middle Name:
Last Name:VARGAS CORRALES
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 1:3680 E IMPERIAL HWY STE 220
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-2663
Mailing Address - Country:US
Mailing Address - Phone:323-806-4993
Mailing Address - Fax:
Practice Address - Street 1:3680 E IMPERIAL HWY STE 220
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2663
Practice Address - Country:US
Practice Address - Phone:323-769-7135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY7840995Medicaid