Basic Information
Provider Information | |||||||||
NPI: | 1003353319 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VARGAS | ||||||||
FirstName: | JACQUELYN | ||||||||
MiddleName: | CELESTINA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | AMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VARGAS | ||||||||
OtherFirstName: | JACKIE | ||||||||
OtherMiddleName: | CELESTINA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 555 N PERRIS BLVD | ||||||||
Address2: |   | ||||||||
City: | PERRIS | ||||||||
State: | CA | ||||||||
PostalCode: | 925712811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9514365366 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 555 N PERRIS BLVD | ||||||||
Address2: |   | ||||||||
City: | PERRIS | ||||||||
State: | CA | ||||||||
PostalCode: | 925712811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9514365366 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2017 | ||||||||
LastUpdateDate: | 08/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X |   | CA | N |   |   |   |   | 106H00000X | AMFT133865 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.