Basic Information
| Provider Information | |||||||||
| NPI: | 1700411576 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYES | ||||||||
| FirstName: | JAQUELINA | ||||||||
| MiddleName: | ANDREA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25279 W CENTRE AVE | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853262468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109859501 | ||||||||
| FaxNumber: | 6024554624 | ||||||||
| Practice Location | |||||||||
| Address1: | 25279 W CENTRE AVE | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853262468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109859501 | ||||||||
| FaxNumber: | 6024554624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2020 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385HR2055X | 2656335 | AZ | N | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | 253J00000X | 2656335 | AZ | Y | Agencies | Foster Care Agency |
No ID Information.