Provider Demographics
NPI:1952445165
Name:CHILDS, JACQUELYNNE CELESTE (MFT)
Entity Type:Individual
Prefix:
First Name:JACQUELYNNE
Middle Name:CELESTE
Last Name:CHILDS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 CENTRAL AVE
Mailing Address - Street 2:STE 203
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2374
Mailing Address - Country:US
Mailing Address - Phone:951-684-7177
Mailing Address - Fax:951-788-4486
Practice Address - Street 1:4515 CENTRAL AVE
Practice Address - Street 2:STE 203
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2374
Practice Address - Country:US
Practice Address - Phone:951-684-7177
Practice Address - Fax:951-788-4486
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC27086101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health