Healthcare Provider Details

I. General information

NPI: 1336602606
Provider Name (Legal Business Name): MADISON LYNN JAUREQUI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 08/01/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8910 UNIVERSITY CENTER LANE, SUITE 400
SAN DIEGO CA
92122
US

IV. Provider business mailing address

989 ASHTON CT
VISTA CA
92081
US

V. Phone/Fax

Practice location:
  • Phone: 844-362-7943
  • Fax:
Mailing address:
  • Phone: 951-541-6773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-23-14629
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: