Basic Information
| Provider Information | |||||||||
| NPI: | 1134606148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUREE | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | M.A. BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 MIRA MAR AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908032880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187307849 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1230 ROSECRANS AVE STE 250 | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902662496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104061500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2018 | ||||||||
| LastUpdateDate: | 07/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-18-30244 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 262915096 | 05 | CA | MEDICAID |