Provider Demographics
NPI:1700764867
Name:JACQUEZ, KATIE ELLEN
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ELLEN
Last Name:JACQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12791 REED AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-6029
Mailing Address - Country:US
Mailing Address - Phone:909-648-5407
Mailing Address - Fax:
Practice Address - Street 1:601 5TH AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4839
Practice Address - Country:US
Practice Address - Phone:909-949-6526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach