Provider Demographics
NPI:1437803228
Name:VASQUEZ, TAYLOR A
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:A
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:A
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4309 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1407
Mailing Address - Country:US
Mailing Address - Phone:619-876-4502
Mailing Address - Fax:
Practice Address - Street 1:4309 3RD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1407
Practice Address - Country:US
Practice Address - Phone:619-876-4502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
172V00000X172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician