Healthcare Provider Details

I. General information

NPI: 1124519335
Provider Name (Legal Business Name): MARYELLIE JACQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S LA CADENA DR
COLTON CA
92324-3419
US

IV. Provider business mailing address

301 S LA CADENA DR
COLTON CA
92324-3419
US

V. Phone/Fax

Practice location:
  • Phone: 909-219-5260
  • Fax: 909-264-3728
Mailing address:
  • Phone: 909-219-5260
  • Fax: 909-264-3728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberD5897194
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: