Provider Demographics
NPI:1144054735
Name:FUENTES, JACQUELINE (PHD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FUENTES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 ALICE RODRIGUEZ CIR
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-3902
Mailing Address - Country:US
Mailing Address - Phone:626-320-0178
Mailing Address - Fax:
Practice Address - Street 1:3250 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1577
Practice Address - Country:US
Practice Address - Phone:323-361-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist