Provider Demographics
NPI:1679610422
Name:GANG, JACLYN H (PHD, MFT)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:H
Last Name:GANG
Suffix:
Gender:F
Credentials:PHD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4252
Mailing Address - Country:US
Mailing Address - Phone:760-741-7771
Mailing Address - Fax:760-747-5474
Practice Address - Street 1:135 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4252
Practice Address - Country:US
Practice Address - Phone:760-741-7771
Practice Address - Fax:760-747-5474
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMC20522106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMC20522OtherMFT LICENSE