Provider Demographics
NPI:1558719799
Name:PADILLA, JACLYN MARIE
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:PADILLA
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:PO BOX 2931
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91793-2931
Mailing Address - Country:US
Mailing Address - Phone:323-384-2388
Mailing Address - Fax:
Practice Address - Street 1:5400 E OLYMPIC BLVD FL 1
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90022-5147
Practice Address - Country:US
Practice Address - Phone:323-869-9255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-27
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT131241106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist