Provider Demographics
NPI:1073331500
Name:PEGUERO, JAZMIN PALACIOS (PPS)
Entity type:Individual
Prefix:
First Name:JAZMIN
Middle Name:PALACIOS
Last Name:PEGUERO
Suffix:
Gender:F
Credentials:PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2467 E SONORA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-6508
Mailing Address - Country:US
Mailing Address - Phone:209-623-3204
Mailing Address - Fax:
Practice Address - Street 1:248 W A ST
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-2449
Practice Address - Country:US
Practice Address - Phone:209-745-2641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240131502101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool