Provider Demographics
NPI:1235682089
Name:HACKETT, JENNIFER PARKER
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:PARKER
Last Name:HACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:PARKER
Other - Last Name:AYLWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10259 STAFFORD ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3045
Mailing Address - Country:US
Mailing Address - Phone:951-836-8622
Mailing Address - Fax:
Practice Address - Street 1:11201 BENTON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-4238
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC133431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program