Provider Demographics
NPI:1417779315
Name:REYES CARRANZA, JACQUELINE (MSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:REYES CARRANZA
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 1:101 KENWOOD ST APT 108
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-1627
Mailing Address - Country:US
Mailing Address - Phone:509-540-8292
Mailing Address - Fax:
Practice Address - Street 1:380 CHASE AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2924
Practice Address - Country:US
Practice Address - Phone:509-897-8600
Practice Address - Fax:509-897-5872
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASA61600768104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker