Provider Demographics
NPI:1912701392
Name:CELIS, JACQUELINE ELENA
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELENA
Last Name:CELIS
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 1:401 S INGLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-2599
Mailing Address - Country:US
Mailing Address - Phone:310-419-2700
Mailing Address - Fax:
Practice Address - Street 1:215 W 94TH ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-3701
Practice Address - Country:US
Practice Address - Phone:310-680-5410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool