Provider Demographics
NPI:1588035778
Name:DE MARIA, JACQUELINE (MCP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DE MARIA
Suffix:
Gender:F
Credentials:MCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 W 7TH ST APT 10
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-3953
Mailing Address - Country:US
Mailing Address - Phone:213-610-3001
Mailing Address - Fax:
Practice Address - Street 1:2930 W 7TH ST APT 10
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-3953
Practice Address - Country:US
Practice Address - Phone:213-610-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF80356106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIMF80356OtherBOARD OF BEHAVIORAL SCIENCES