Provider Demographics
NPI:1699172080
Name:GARDNER, JACQUELYN L
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:L
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1947 DIVISADERO ST.
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAN FRANCISCO, C
Mailing Address - State:CA
Mailing Address - Zip Code:94115
Mailing Address - Country:US
Mailing Address - Phone:415-441-4350
Mailing Address - Fax:415-614-1760
Practice Address - Street 1:1947 DIVISADERO ST.
Practice Address - Street 2:STE. 2
Practice Address - City:SAN FRANCISCO,
Practice Address - State:CA
Practice Address - Zip Code:94115
Practice Address - Country:US
Practice Address - Phone:415-441-4350
Practice Address - Fax:415-614-1760
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7469103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical