Provider Demographics
NPI:1063033611
Name:WAX, JACQLYN QUINTINA (PSYD)
Entity Type:Individual
Prefix:
First Name:JACQLYN
Middle Name:QUINTINA
Last Name:WAX
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 BLUE SKY DR
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-1005
Mailing Address - Country:US
Mailing Address - Phone:858-213-7243
Mailing Address - Fax:
Practice Address - Street 1:27201 PUERTA REAL STE 300
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-8590
Practice Address - Country:US
Practice Address - Phone:949-354-4147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94024446103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist