Provider Demographics
NPI:1487379350
Name:VANDENBERG, JAQUELINE REGINA (BEHAVIOR TECHNICIAN)
Entity type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:REGINA
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:JAQUELINE
Other - Middle Name:REGINA
Other - Last Name:MONROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1500 S DOUGLAS RD STE 230
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4108
Mailing Address - Country:US
Mailing Address - Phone:844-854-1116
Mailing Address - Fax:
Practice Address - Street 1:1545 68TH ST SE STE 201
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-7896
Practice Address - Country:US
Practice Address - Phone:844-854-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician