Provider Demographics
NPI:1063904159
Name:SOSA-TORRES, JACQUELINE JULISSA
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:JULISSA
Last Name:SOSA-TORRES
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 1:18612 SANTA ANA AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:92316-2636
Mailing Address - Country:US
Mailing Address - Phone:909-844-9994
Mailing Address - Fax:
Practice Address - Street 1:18612 SANTA ANA AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:CA
Practice Address - Zip Code:92316-2636
Practice Address - Country:US
Practice Address - Phone:909-421-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program