Basic Information
| Provider Information | |||||||||
| NPI: | 1093173858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ACSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 PINE AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908023041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622432976 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 456 ELM AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908022426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624376717 | ||||||||
| FaxNumber: | 5624375072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2016 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | 95719 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.