Provider Demographics
NPI:1912297300
Name:MEDINA, JACQUELINE FRANCINE (CAC II)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:FRANCINE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:CAC II
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:FRANCINE
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CAC II
Mailing Address - Street 1:1301 ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-3541
Mailing Address - Country:US
Mailing Address - Phone:719-937-3394
Mailing Address - Fax:
Practice Address - Street 1:2265 LAVA LN
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-3578
Practice Address - Country:US
Practice Address - Phone:719-589-5176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7185251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health