Provider Demographics
NPI:1356891550
Name:VALDES CHAVEZ, JACQUELINE BEATRIZ
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:BEATRIZ
Last Name:VALDES CHAVEZ
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 1:10345 SW 135TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-2842
Mailing Address - Country:US
Mailing Address - Phone:786-800-0842
Mailing Address - Fax:
Practice Address - Street 1:18505 NW 75TH PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-2961
Practice Address - Country:US
Practice Address - Phone:786-479-0029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019001700Medicaid