Provider Demographics
NPI:1275349102
Name:WHEELER, JACQUELINE HANSON (PSYD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:HANSON
Last Name:WHEELER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-6837
Mailing Address - Country:US
Mailing Address - Phone:310-804-4998
Mailing Address - Fax:
Practice Address - Street 1:2444 WILSHIRE BLVD STE 620
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5828
Practice Address - Country:US
Practice Address - Phone:424-281-9433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X
NA103T00000X
CA94026263103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist