Provider Demographics
NPI:1073210837
Name:AVILA, JACQUELYN LYNN (SUDRC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:LYNN
Last Name:AVILA
Suffix:
Gender:F
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 N INDIAN CANYON DR STE A
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-4880
Mailing Address - Country:US
Mailing Address - Phone:760-322-9065
Mailing Address - Fax:
Practice Address - Street 1:1330 N INDIAN CANYON DR STE A
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4880
Practice Address - Country:US
Practice Address - Phone:760-322-9065
Practice Address - Fax:760-322-8916
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14458101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)