Provider Demographics
NPI:1023184611
Name:JACQUES, REBECCA L (MA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:JACQUES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2289
Mailing Address - Street 2:
Mailing Address - City:BLYTHE
Mailing Address - State:CA
Mailing Address - Zip Code:92226-2289
Mailing Address - Country:US
Mailing Address - Phone:760-922-5300
Mailing Address - Fax:
Practice Address - Street 1:734 10TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6502
Practice Address - Country:US
Practice Address - Phone:619-239-4663
Practice Address - Fax:619-239-3035
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26263103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical