MEDICARE: JACKIE CAMARENA MFT TRAINEE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1316216237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE CAMARENA MFT TRAINEE

Provider Business Mailing Address
First Line	:	1862 INDIANAPOLIS AVE
Second Line	:
City	:	CLOVIS
State	:	CA
Zip	:	93611-5262
Country	:	US
Telephone Number	:	559-248-8550
Fax Number	:	559-248-8555

Provider Business Practice Location Address
First Line	:	5168 N BLYTHE AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93722-6477
Country	:	US
Telephone Number	:	559-248-8550
Fax Number	:	559-248-8555

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2011
Last Update Date	:	12/06/2013

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