Healthcare Provider Details

I. General information

NPI: 1477068005
Provider Name (Legal Business Name): JACOBO MACHUCA REYES BA, CADCIII
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N LA BREA AVE
INGLEWOOD CA
90302-3049
US

IV. Provider business mailing address

3114 PATRITTI AVE
BALDWIN PARK CA
91706-3503
US

V. Phone/Fax

Practice location:
  • Phone: 323-933-9022
  • Fax: 323-933-4029
Mailing address:
  • Phone: 323-636-1716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberR1282711117
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberB00003761224
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: