Provider Demographics
NPI:1174682009
Name:BUSTAMANTE, JACKIE LYNN
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:LYNN
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 CLARK AVE # 109
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-3801
Mailing Address - Country:US
Mailing Address - Phone:562-706-1072
Mailing Address - Fax:866-678-7357
Practice Address - Street 1:1716 CLARK AVE STE 109
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-3801
Practice Address - Country:US
Practice Address - Phone:562-706-1072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30317106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist