Provider Demographics
NPI:1942850094
Name:CLEGHORN, JACQUELINE RENAE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENAE
Last Name:CLEGHORN
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 1:22840 NE 8TH ST APT 214
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074-7262
Mailing Address - Country:US
Mailing Address - Phone:623-363-3316
Mailing Address - Fax:
Practice Address - Street 1:6505 218TH ST SW STE 12
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2135
Practice Address - Country:US
Practice Address - Phone:425-563-1093
Practice Address - Fax:425-329-4535
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician