Basic Information
| Provider Information | |||||||||
| NPI: | 1629484043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19019 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913563253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183452345 | ||||||||
| FaxNumber: | 8187588015 | ||||||||
| Practice Location | |||||||||
| Address1: | 5152 BROADWAY ST | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782095735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108241566 | ||||||||
| FaxNumber: | 8187588015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2014 | ||||||||
| LastUpdateDate: | 03/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-14-16614 | TX | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.