Provider Demographics
NPI:1083948046
Name:GAMBOA, JACQUELINE MICHELLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MICHELLE
Last Name:GAMBOA
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:PO BOX 904
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92038-0904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12625 HIGH BLUFF DR
Practice Address - Street 2:SUITE 114
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2052
Practice Address - Country:US
Practice Address - Phone:858-492-8445
Practice Address - Fax:858-492-8445
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22784103TA0400X, 103TC0700X, 103TC2200X, 103TF0000X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities