1114180114 NPI number — JACQUELINE BALTIERRA JAKOB MSW

Table of content: JACQUELINE BALTIERRA JAKOB MSW (NPI 1114180114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114180114 NPI number — JACQUELINE BALTIERRA JAKOB MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAKOB
Provider First Name:
JACQUELINE
Provider Middle Name:
BALTIERRA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JAKOB
Provider Other First Name:
JACKIE
Provider Other Middle Name:
BALTIERRA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1114180114
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5675 TELEGRAPH RD
Provider Second Line Business Mailing Address:
SUITE 260
Provider Business Mailing Address City Name:
COMMERCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90040-1570
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-838-9566
Provider Business Mailing Address Fax Number:
323-838-9573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5675 TELEGRAPH RD
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
COMMERCE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90040-1570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-838-9566
Provider Business Practice Location Address Fax Number:
323-838-9573
Provider Enumeration Date:
07/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ASW 23726 . This is a "BOARD OF BEHAVIORAL SCIENCES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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