Provider Demographics
NPI:1730557190
Name:MARQUEZ, JASMINE
Entity type:Individual
Prefix:MS
First Name:JASMINE
Middle Name:
Last Name:MARQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 BALBOA ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-3101
Mailing Address - Country:US
Mailing Address - Phone:323-348-0113
Mailing Address - Fax:
Practice Address - Street 1:684 ELLIS ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-8090
Practice Address - Country:US
Practice Address - Phone:415-852-5300
Practice Address - Fax:415-749-2791
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF73239106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1720385032Medicaid