Provider Demographics
NPI:1972023802
Name:WAITE, JACLYN KYRA (LCSW)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:KYRA
Last Name:WAITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 W LAMBERT RD
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-4042
Mailing Address - Country:US
Mailing Address - Phone:714-598-2052
Mailing Address - Fax:
Practice Address - Street 1:250 W 1ST ST STE 214
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4743
Practice Address - Country:US
Practice Address - Phone:909-451-9941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83988101YM0800X
390200000X
CA986151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program