Provider Demographics
NPI:1467908889
Name:DELONG, JACLYN (LCSW)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:DELONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S LONG BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-3423
Mailing Address - Country:US
Mailing Address - Phone:310-627-5850
Mailing Address - Fax:
Practice Address - Street 1:121 S LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-3423
Practice Address - Country:US
Practice Address - Phone:310-627-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACB.0007954101YA0400X
CONLC.0105727101YM0800X
CA887551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO84902248Medicaid