Provider Demographics
NPI:1245435932
Name:PARKE, JACQUELINE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:PARKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:MOONILAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1370 BREA BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4125
Mailing Address - Country:US
Mailing Address - Phone:714-451-6327
Mailing Address - Fax:
Practice Address - Street 1:1370 BREA BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4125
Practice Address - Country:US
Practice Address - Phone:714-451-6327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24269103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical