Provider Demographics
NPI:1265873483
Name:GARCIA, JACLYN ANTOINETTE
Entity type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:ANTOINETTE
Last Name:GARCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:ANTIOINETTE
Other - Last Name:GALVEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2495 W MARCH LN STE 125
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8224
Mailing Address - Country:US
Mailing Address - Phone:209-465-1080
Mailing Address - Fax:
Practice Address - Street 1:2495 W MARCH LN STE 125
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8224
Practice Address - Country:US
Practice Address - Phone:209-465-1080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75270106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist