Provider Demographics
NPI:1700638905
Name:DE LA PAZ, JACQUELINE
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:DE LA PAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JACKY
Other - Middle Name:
Other - Last Name:DE LA PAZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3307 CALDWELL BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-6403
Mailing Address - Country:US
Mailing Address - Phone:208-465-4833
Mailing Address - Fax:208-467-2654
Practice Address - Street 1:3307 CALDWELL BLVD STE 104
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-6403
Practice Address - Country:US
Practice Address - Phone:208-465-4833
Practice Address - Fax:208-467-2654
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health