Provider Demographics
NPI:1194440651
Name:BAUTISTA, JACQUELINE ALEJANDRA (MSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ALEJANDRA
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14344 CAJON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-4301
Mailing Address - Country:US
Mailing Address - Phone:760-243-3999
Mailing Address - Fax:
Practice Address - Street 1:14344 CAJON AVE STE 102
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-4301
Practice Address - Country:US
Practice Address - Phone:760-243-3999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-07
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW1128651041C0700X
CA112865104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical