Provider Demographics
NPI:1063649135
Name:EYERLY, JACQUELINE (MA;MS;LMFT;LPCC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:EYERLY
Suffix:
Gender:F
Credentials:MA;MS;LMFT;LPCC
Other - Prefix:PROF
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:EYERLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT;LPCC
Mailing Address - Street 1:1748 HILL ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-4844
Mailing Address - Country:US
Mailing Address - Phone:213-434-5988
Mailing Address - Fax:
Practice Address - Street 1:550 S VERMONT AVE FL 10
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1912
Practice Address - Country:US
Practice Address - Phone:213-434-5988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC49003101YM0800X, 106H00000X
CALPCC#675101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC#49003OtherBOARD OF BEHAVIORAL SCIENCES
CAMFC#49003OtherLICENSED MARRIAGE & FAMILY THERAPIST
CALPCC#675OtherBOARD OF BEHAVIORAL SCIENCES
CALPCC#675OtherLICENSED PROFESSIONAL CLINICAL COUNSELOR