Basic Information
Provider Information | |||||||||
NPI: | 1225591951 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLORES | ||||||||
FirstName: | JACLYN | ||||||||
MiddleName: | ELENA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RBT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1039 JOSHUA ST | ||||||||
Address2: |   | ||||||||
City: | ESCONDIDO | ||||||||
State: | CA | ||||||||
PostalCode: | 920263032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7605002002 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7090 MIRATECH DR | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921213109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8583046440 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2019 | ||||||||
LastUpdateDate: | 06/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X |   | CA | N |   |   |   |   | 106S00000X |   | CA | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 680317191 | 01 |   | MEDI-CAL | OTHER |