Provider Demographics
NPI:1467807297
Name:HERNANDEZ, JACQUELYN (MFT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10808 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3889
Mailing Address - Country:US
Mailing Address - Phone:323-484-3571
Mailing Address - Fax:
Practice Address - Street 1:10808 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3889
Practice Address - Country:US
Practice Address - Phone:323-484-3571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 77759101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health