Provider Demographics
NPI:1821605379
Name:KING, JACQUELAN ADDESAN (LPC)
Entity type:Individual
Prefix:
First Name:JACQUELAN
Middle Name:ADDESAN
Last Name:KING
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:JACQUELAN
Other - Middle Name:ADDESAN
Other - Last Name:VUJOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:124 5TH ST APT A
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-8000
Mailing Address - Country:US
Mailing Address - Phone:406-579-3777
Mailing Address - Fax:
Practice Address - Street 1:124 5TH ST APT A
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-8000
Practice Address - Country:US
Practice Address - Phone:406-579-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76272101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional