Provider Demographics
NPI:1972639581
Name:SUDARIA, JACQUELINNE (LMFT)
Entity Type:Individual
Prefix:
First Name:JACQUELINNE
Middle Name:
Last Name:SUDARIA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MOBIL AVE.
Mailing Address - Street 2:SUITE A1-RC
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-1044
Mailing Address - Country:US
Mailing Address - Phone:805-389-4380
Mailing Address - Fax:805-389-3246
Practice Address - Street 1:400 MOBIL AVE.
Practice Address - Street 2:SUITE A1-RC
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-1044
Practice Address - Country:US
Practice Address - Phone:805-389-4380
Practice Address - Fax:805-389-3246
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51416106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist