Provider Demographics
NPI:1316495039
Name:LIMA, JACQUELINE S
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:S
Last Name:LIMA
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 1:510 S VERMONT AVE FL 17
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1912
Mailing Address - Country:US
Mailing Address - Phone:213-392-4413
Mailing Address - Fax:213-947-4579
Practice Address - Street 1:510 S VERMONT AVE FL 17
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1912
Practice Address - Country:US
Practice Address - Phone:213-392-4413
Practice Address - Fax:213-947-4579
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW2983PMedicare PIN