Provider Demographics
NPI:1811430622
Name:MOBLEY, JACQUELINE (CADCII)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:MOBLEY
Suffix:
Gender:F
Credentials:CADCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 PRADO ROAD
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34 PRADO ROAD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-457-3331
Practice Address - Fax:805-457-3332
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC034330315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR15-R-26OtherACCBO