Provider Demographics
NPI:1104624659
Name:MEDINA, JAQUELINE GUADALUPE
Entity type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:GUADALUPE
Last Name:MEDINA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 S STONEMAN ST.
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802
Mailing Address - Country:US
Mailing Address - Phone:714-728-5145
Mailing Address - Fax:
Practice Address - Street 1:17011 BEACH BLVD STE 900
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5998
Practice Address - Country:US
Practice Address - Phone:714-602-4820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician