Provider Demographics
NPI:1659754794
Name:LUNA, JACQUELINE LARA
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LARA
Last Name:LUNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12968 FREDERICK ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5229
Mailing Address - Country:US
Mailing Address - Phone:951-242-7738
Mailing Address - Fax:951-242-7733
Practice Address - Street 1:12968 FREDERICK ST
Practice Address - Street 2:SUITE D
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5229
Practice Address - Country:US
Practice Address - Phone:951-242-7738
Practice Address - Fax:951-242-7733
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist