Provider Demographics
NPI:1477068005
Name:REYES, JACOBO MACHUCA (BA, CADCIII)
Entity type:Individual
Prefix:
First Name:JACOBO
Middle Name:MACHUCA
Last Name:REYES
Suffix:
Gender:M
Credentials:BA, CADCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3114 PATRITTI AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3503
Mailing Address - Country:US
Mailing Address - Phone:323-636-1716
Mailing Address - Fax:
Practice Address - Street 1:520 N LA BREA AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-3049
Practice Address - Country:US
Practice Address - Phone:323-933-9022
Practice Address - Fax:323-933-4029
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB00003761224101YA0400X
CAR1282711117101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor