Provider Demographics
NPI:1104361203
Name:SUMMERS, JACQUELYN (PHD, MPH, MSW)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:PHD, MPH, MSW
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 181171
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92178-1171
Mailing Address - Country:US
Mailing Address - Phone:619-446-9631
Mailing Address - Fax:
Practice Address - Street 1:915 I AVE
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-2449
Practice Address - Country:US
Practice Address - Phone:619-446-9631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-27
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW171671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical