Provider Demographics
NPI:1528351897
Name:VAZQUEZ, JAMIE R
Entity type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:R
Last Name:VAZQUEZ
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 1:1522 E 102ND ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002-3338
Mailing Address - Country:US
Mailing Address - Phone:323-523-8689
Mailing Address - Fax:
Practice Address - Street 1:1522 E 102ND ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3338
Practice Address - Country:US
Practice Address - Phone:323-523-8689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 60493101YM0800X
CA53055106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health