Provider Demographics
NPI:1124542642
Name:NGUYEN, JACQUELYN (PSYD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:NGUYEN
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 1:1011 N BEGONIA AVE STE 1009
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-2104
Mailing Address - Country:US
Mailing Address - Phone:323-786-2425
Mailing Address - Fax:
Practice Address - Street 1:1011 N BEGONIA AVE STE 1009
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-2104
Practice Address - Country:US
Practice Address - Phone:323-786-2425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31128103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist