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General NPI Number Information
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NPI Number | 1134644115
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Entity Type | Individual
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Provider Name | JORGE VASQUEZ CADC-I
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Gender | Male
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Dates
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Enumeration Date | 08/10/2017
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Last Update Date | 01/27/2020
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Provider Practice Location Address
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Address Line | 222 W HOSPITALITY LN
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City | SAN BERNARDINO
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State | CA
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Zip | 92415-3536
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Country | US
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Telephone | 909-421-4601
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1221
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City | GLENDORA
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State | CA
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Zip | 91740-1221
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Country | US
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Telephone | 949-478-3849
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CICA01850919
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License Number State | CA
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