Provider Demographics
NPI:1093247025
Name:GUTIERREZ, JACQUELINE ROSE (MS, LMFT 122964)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ROSE
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MS, LMFT 122964
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11731 TELEGRAPH RD STE K
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-6815
Mailing Address - Country:US
Mailing Address - Phone:626-802-8247
Mailing Address - Fax:
Practice Address - Street 1:11731 TELEGRAPH RD STE K
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-6815
Practice Address - Country:US
Practice Address - Phone:626-802-8247
Practice Address - Fax:626-967-6027
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT122964106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist