Provider Demographics
NPI:1093173858
Name:CHANG, JACQUELYN R (ACSW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:R
Last Name:CHANG
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-3041
Mailing Address - Country:US
Mailing Address - Phone:562-243-2976
Mailing Address - Fax:
Practice Address - Street 1:456 ELM AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-2426
Practice Address - Country:US
Practice Address - Phone:562-437-6717
Practice Address - Fax:562-437-5072
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA95719104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health