Provider Demographics
NPI:1043860752
Name:BIXBY, JACQUELINE S
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:S
Last Name:BIXBY
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 1:6762 LOS VERDES DR APT 2
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-7610
Mailing Address - Country:US
Mailing Address - Phone:323-445-4402
Mailing Address - Fax:
Practice Address - Street 1:2200 PACIFIC COAST HWY STE 304A
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2702
Practice Address - Country:US
Practice Address - Phone:323-445-4402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-14
Last Update Date:2019-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA114667101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor