Provider Demographics
NPI:1548385552
Name:NALLS, JACQUELYN ASHLEY (MFTI)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:ASHLEY
Last Name:NALLS
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24006 BRIDGEPORT LN
Mailing Address - Street 2:SUITE 49
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1697
Mailing Address - Country:US
Mailing Address - Phone:661-255-6847
Mailing Address - Fax:
Practice Address - Street 1:21545 CENTRE POINTE PKWY
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91350-2947
Practice Address - Country:US
Practice Address - Phone:661-255-6847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF52561225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner