Provider Demographics
NPI:1457609802
Name:VASQUEZ, JASON (PHD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:PHD
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 474
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-0474
Mailing Address - Country:US
Mailing Address - Phone:951-394-1423
Mailing Address - Fax:
Practice Address - Street 1:7065 INDIANA AVE STE 110
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4167
Practice Address - Country:US
Practice Address - Phone:951-394-1423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008407103TC0700X
CA29584103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical