Provider Demographics
NPI:1255967170
Name:SOLIS, JACQUELINE JULISSA (CMT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JULISSA
Last Name:SOLIS
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28029 SARABANDE LN UNIT 1226
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91387-5437
Mailing Address - Country:US
Mailing Address - Phone:818-212-4869
Mailing Address - Fax:
Practice Address - Street 1:28029 SARABANDE LN UNIT 1226
Practice Address - Street 2:
Practice Address - City:CANYON COUNTRY
Practice Address - State:CA
Practice Address - Zip Code:91387-5437
Practice Address - Country:US
Practice Address - Phone:818-212-4869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82455225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA82455OtherCAMTC