Provider Demographics
NPI:1124759766
Name:DESHONG, JACQUELYN (LMFT)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:DESHONG
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 1:4 SCIENCE PARK
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-1962
Mailing Address - Country:US
Mailing Address - Phone:844-830-7233
Mailing Address - Fax:
Practice Address - Street 1:16701 MELFORD BLVD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4305
Practice Address - Country:US
Practice Address - Phone:844-830-7233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001698-01106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist