Healthcare Provider Details

I. General information

NPI: 1700411576
Provider Name (Legal Business Name): JAQUELINA ANDREA REYES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25279 W CENTRE AVE
BUCKEYE AZ
85326-2468
US

IV. Provider business mailing address

25279 W CENTRE AVE
BUCKEYE AZ
85326-2468
US

V. Phone/Fax

Practice location:
  • Phone: 310-985-9501
  • Fax: 602-455-4624
Mailing address:
  • Phone: 310-985-9501
  • Fax: 602-455-4624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number2656335
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number2656335
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: