Provider Demographics
NPI:1609054295
Name:HARDIE, JACQUELYN ANN (MFT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:ANN
Last Name:HARDIE
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 1:3144 WHITE CEDAR PL
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-4903
Mailing Address - Country:US
Mailing Address - Phone:805-358-0817
Mailing Address - Fax:
Practice Address - Street 1:3144 WHITE CEDAR PL
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-4903
Practice Address - Country:US
Practice Address - Phone:805-358-0817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 20090106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist