Provider Demographics
NPI:1215118385
Name:MILLHAM, JACQUELYN D (PHD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:D
Last Name:MILLHAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 N OAK KNOLL AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-4170
Mailing Address - Country:US
Mailing Address - Phone:626-796-7495
Mailing Address - Fax:626-796-4447
Practice Address - Street 1:181 N OAK KNOLL AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-4170
Practice Address - Country:US
Practice Address - Phone:626-796-7495
Practice Address - Fax:626-796-4447
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-17
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20029103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical