Provider Demographics
NPI:1477807352
Name:FLY, JACKULINE D
Entity Type:Individual
Prefix:MS
First Name:JACKULINE
Middle Name:D
Last Name:FLY
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 1:24442 VALENCIA BLVD
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1825
Mailing Address - Country:US
Mailing Address - Phone:661-312-3905
Mailing Address - Fax:
Practice Address - Street 1:24442 VALENCIA BLVD
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-1825
Practice Address - Country:US
Practice Address - Phone:661-312-3905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34101104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker