Provider Demographics
NPI:1790546125
Name:BRIDGE ACADEMY COLLECTIVE
Entity type:Organization
Organization Name:BRIDGE ACADEMY COLLECTIVE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:MACK-HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, PSYD
Authorized Official - Phone:949-275-2979
Mailing Address - Street 1:19917 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-0400
Mailing Address - Country:US
Mailing Address - Phone:949-275-2979
Mailing Address - Fax:951-356-7325
Practice Address - Street 1:2904 BREA BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2015
Practice Address - Country:US
Practice Address - Phone:951-805-3467
Practice Address - Fax:951-356-7325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty