MEDICARE: JACQUELINE MEDINA

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	:	1942943774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE MEDINA

Provider Business Mailing Address
First Line	:	743 N PHILADELPHIA ST
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92805-2738
Country	:	US
Telephone Number	:	714-768-0774
Fax Number	:

Provider Business Practice Location Address
First Line	:	743 N PHILADELPHIA ST
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92805-2738
Country	:	US
Telephone Number	:	714-768-0774
Fax Number	:

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

Provider Enumeration Date	:	04/19/2022
Last Update Date	:	04/19/2022

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Directions to “ JACQUELINE MEDINA ” Practice Location

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