Provider Demographics
NPI:1891196077
Name:GRACE, JACLYN A
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:A
Last Name:GRACE
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 1:1430 EAST AVE STE 2B
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-1629
Mailing Address - Country:US
Mailing Address - Phone:530-433-4354
Mailing Address - Fax:
Practice Address - Street 1:555 SOQUEL AVE STE 260
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2340
Practice Address - Country:US
Practice Address - Phone:831-440-8095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist