Basic Information
| Provider Information | |||||||||
| NPI: | 1750946547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PULIDO | ||||||||
| FirstName: | JACQUELYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2677 ZOE AVE STE 304 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902553699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233460960 | ||||||||
| FaxNumber: | 3233460966 | ||||||||
| Practice Location | |||||||||
| Address1: | 679 S NEW HAMPSHIRE AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900051355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136390298 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2019 | ||||||||
| LastUpdateDate: | 03/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.