Provider Demographics
NPI:1124519335
Name:JACQUEZ, MARYELLIE
Entity type:Individual
Prefix:
First Name:MARYELLIE
Middle Name:
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 1:301 S LA CADENA DR
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3419
Mailing Address - Country:US
Mailing Address - Phone:909-219-5260
Mailing Address - Fax:909-264-3728
Practice Address - Street 1:301 S LA CADENA DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3419
Practice Address - Country:US
Practice Address - Phone:909-219-5260
Practice Address - Fax:909-264-3728
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2025-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD5897194103K00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No172V00000XOther Service ProvidersCommunity Health Worker