MEDICARE: MIRACLE JACQUEZ CHW

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	172V00000X	Community Health Worker	CHW	CA

General Provider Information

NPI Number	:	1760329734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRACLE JACQUEZ CHW

Provider Business Mailing Address
First Line	:	990 W MILL ST
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92410-2636
Country	:	US
Telephone Number	:	909-884-9171
Fax Number	:

Provider Business Practice Location Address
First Line	:	990 W MILL ST
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92410-2636
Country	:	US
Telephone Number	:	909-884-9171
Fax Number	:

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

Provider Enumeration Date	:	04/29/2026
Last Update Date	:	04/29/2026

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