Provider Demographics
NPI:1093259715
Name:ZECCOLA, JACLYN (PHD)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:ZECCOLA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11712 MOORPARK ST STE 204B
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2158
Mailing Address - Country:US
Mailing Address - Phone:323-636-1632
Mailing Address - Fax:
Practice Address - Street 1:11712 MOORPARK ST STE 204B
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2158
Practice Address - Country:US
Practice Address - Phone:323-636-1632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB37634103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist