Provider Demographics
NPI:1568759017
Name:PAYNE, JACQUELINE LOIS (MA)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:LOIS
Last Name:PAYNE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 E. CAMPBELL AVENUE
Mailing Address - Street 2:SUITE 10B
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-2134
Mailing Address - Country:US
Mailing Address - Phone:408-866-8988
Mailing Address - Fax:
Practice Address - Street 1:621 E. CAMPBELL AVENUE
Practice Address - Street 2:SUITE 10B
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-2134
Practice Address - Country:US
Practice Address - Phone:408-866-8988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT23118106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist