Provider Demographics
NPI:1063190304
Name:HENRY, JACQUELYN PAULINE (APCC)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:PAULINE
Last Name:HENRY
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 NINTH ST
Mailing Address - Street 2:UNIT 301
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374
Mailing Address - Country:US
Mailing Address - Phone:909-747-2126
Mailing Address - Fax:
Practice Address - Street 1:301 NINTH ST
Practice Address - Street 2:UNIT 301
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374
Practice Address - Country:US
Practice Address - Phone:909-747-2126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5668101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health