Provider Demographics
NPI:1578705117
Name:ESPINOSA, JACQULYN POLITO (MFTI)
Entity Type:Individual
Prefix:
First Name:JACQULYN
Middle Name:POLITO
Last Name:ESPINOSA
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:JACKI
Other - Middle Name:
Other - Last Name:ESPINOSA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFTI
Mailing Address - Street 1:21250 BOX SPRINGS RD
Mailing Address - Street 2:STE 106
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-8705
Mailing Address - Country:US
Mailing Address - Phone:951-369-8036
Mailing Address - Fax:
Practice Address - Street 1:21250 BOX SPRINGS RD
Practice Address - Street 2:STE 106
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-8705
Practice Address - Country:US
Practice Address - Phone:951-369-8036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62853106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist