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 1:4495 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-3327
Mailing Address - Country:US
Mailing Address - Phone:909-844-9994
Mailing Address - Fax:
Practice Address - Street 1:812 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-2714
Practice Address - Country:US
Practice Address - Phone:909-395-0888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)