MEDICARE: AJENE GABRIELLE JUAREZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1124731450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AJENE GABRIELLE JUAREZ

Provider Business Mailing Address
First Line	:	5431 E PONTIAC WAY
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93727-7531
Country	:	US
Telephone Number	:	559-273-5163
Fax Number	:

Provider Business Practice Location Address
First Line	:	1151 E APPLETON ST APT C
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-3584
Country	:	US
Telephone Number	:	559-273-5163
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2023
Last Update Date	:	01/02/2023

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