1578810305 NPI number — MISS JACQUELINE JAG ANAYA L.AC.

Table of content: MISS JACQUELINE JAG ANAYA L.AC. (NPI 1578810305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578810305 NPI number — MISS JACQUELINE JAG ANAYA L.AC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANAYA
Provider First Name:
JACQUELINE
Provider Middle Name:
JAG
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
L.AC.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578810305
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1264 HIGUERA STREET, SUITE 102
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-203-3014
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1264 HIGUERA STREET
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-203-3014
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2012

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: 171100000X , with the licence number:  14504 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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