Healthcare Provider Details

I. General information

NPI: 1144054735
Provider Name (Legal Business Name): JACQUELINE FUENTES PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 WILSHIRE BLVD
LOS ANGELES CA
90010-1577
US

IV. Provider business mailing address

2410 ALICE RODRIGUEZ CIR
DUARTE CA
91010-3902
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2350
  • Fax:
Mailing address:
  • Phone: 626-320-0178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: