Provider Demographics
NPI:1295196996
Name:DAVIS, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:500 JEFFERSON BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95605-2350
Mailing Address - Country:US
Mailing Address - Phone:530-204-9678
Mailing Address - Fax:
Practice Address - Street 1:500 JEFFERSON BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95605-2350
Practice Address - Country:US
Practice Address - Phone:530-204-9678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor