Provider Demographics
NPI:1699392266
Name:LAYTON, JACQUELINE SURESH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:SURESH
Last Name:LAYTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:SURESH
Other - Last Name:CASTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17324 GLENCOE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-7429
Mailing Address - Country:US
Mailing Address - Phone:612-718-0620
Mailing Address - Fax:
Practice Address - Street 1:17324 GLENCOE AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7429
Practice Address - Country:US
Practice Address - Phone:612-718-0620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1085359103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical