Healthcare Provider Details

I. General information

NPI: 1851258669
Provider Name (Legal Business Name): JACQUELINE CALVARY DEHERRERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2026
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11902 ROSECRANS AVE STE D
NORWALK CA
90650-4197
US

IV. Provider business mailing address

3380 E ANDY ST APT 3
LONG BEACH CA
90805-4535
US

V. Phone/Fax

Practice location:
  • Phone: 562-929-7188
  • Fax: 562-929-7575
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: