Provider Demographics
NPI:1598923013
Name:MOSBY, JACQUELYN (MFT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:MOSBY
Suffix:
Gender:F
Credentials:MFT
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 4682
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-0682
Mailing Address - Country:US
Mailing Address - Phone:209-941-2872
Mailing Address - Fax:
Practice Address - Street 1:2626 N CALIFORNIA ST STE J
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5500
Practice Address - Country:US
Practice Address - Phone:209-938-0831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC41311106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist