Healthcare Provider Details

I. General information

NPI: 1295302172
Provider Name (Legal Business Name): JACKELYNE VARGAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 INLAND EMPIRE BLVD
ONTARIO CA
91764-4898
US

IV. Provider business mailing address

832 HERBERT AVE
LOS ANGELES CA
90063-1738
US

V. Phone/Fax

Practice location:
  • Phone: 909-458-1518
  • Fax:
Mailing address:
  • Phone: 323-427-6376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW136991
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW136991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: