Basic Information
| Provider Information | |||||||||
| NPI: | 1134639933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUGINBILL | ||||||||
| FirstName: | JACKLYN | ||||||||
| MiddleName: | ELENA | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15161 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | MIDWAY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926551432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147155337 | ||||||||
| FaxNumber: | 7148936858 | ||||||||
| Practice Location | |||||||||
| Address1: | 15161 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | MIDWAY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926551432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147155337 | ||||||||
| FaxNumber: | 9512795222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2017 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.