Provider Demographics
NPI:1558099978
Name:MERAZ, JUDE (SUD/CHW)
Entity type:Individual
Prefix:
First Name:JUDE
Middle Name:
Last Name:MERAZ
Suffix:
Gender:M
Credentials:SUD/CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-3808
Mailing Address - Country:US
Mailing Address - Phone:323-325-7510
Mailing Address - Fax:
Practice Address - Street 1:7344 MAGNOLIA AVE STE 110
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-3819
Practice Address - Country:US
Practice Address - Phone:951-404-0856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-12
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21929101YA0400X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)