Provider Demographics
NPI:1366163404
Name:ACEVES EQUIHUA, JAIME (MS)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:ACEVES EQUIHUA
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1477 SATURN BLVD APT 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-2913
Mailing Address - Country:US
Mailing Address - Phone:619-838-1146
Mailing Address - Fax:
Practice Address - Street 1:3245 UNIVERSITY AVE STE 1
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-2009
Practice Address - Country:US
Practice Address - Phone:888-724-7240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC12095101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health