Provider Demographics
NPI:1720560709
Name:MACK-HARRIS, JACQUELINE M (PSYD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:M
Last Name:MACK-HARRIS
Suffix:
Gender:F
Credentials:PSYD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19917 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-0400
Mailing Address - Country:US
Mailing Address - Phone:949-275-2979
Mailing Address - Fax:
Practice Address - Street 1:41197 GOLDEN GATE CIR STE 207
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-6999
Practice Address - Country:US
Practice Address - Phone:951-805-3467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102490106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist