Provider Demographics
NPI:1003091760
Name:LYLE, JACQUELIN L
Entity Type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:L
Last Name:LYLE
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 1:1735 MELROSE AVE UNIT 53
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6572
Mailing Address - Country:US
Mailing Address - Phone:619-426-0926
Mailing Address - Fax:
Practice Address - Street 1:1735 MELROSE AVE UNIT 53
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6572
Practice Address - Country:US
Practice Address - Phone:619-426-0926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)