Basic Information
| Provider Information | |||||||||
| NPI: | 1194465195 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASQUEZ | ||||||||
| FirstName: | JORGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 857 | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917400857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6266659504 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1160 S GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917405000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263355980 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2022 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW97214 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.