Provider Demographics
NPI:1700248655
Name:STOCKHAM, JACLYN B (SUDCC)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:B
Last Name:STOCKHAM
Suffix:
Gender:F
Credentials:SUDCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25612 BARTON RD # 286
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3110
Mailing Address - Country:US
Mailing Address - Phone:800-474-4848
Mailing Address - Fax:
Practice Address - Street 1:1971 ESSEX CT
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8057
Practice Address - Country:US
Practice Address - Phone:800-474-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-21
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)