Provider Demographics
NPI:1780905000
Name:BROCK, JACQUELINE D (LMFT)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:D
Last Name:BROCK
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 1:760 N EUCLID ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-4133
Mailing Address - Country:US
Mailing Address - Phone:323-893-5522
Mailing Address - Fax:323-728-3911
Practice Address - Street 1:760 N EUCLID ST
Practice Address - Street 2:SUITE 108
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-4133
Practice Address - Country:US
Practice Address - Phone:323-893-5522
Practice Address - Fax:323-728-3911
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47723106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist