Provider Demographics
NPI:1023355021
Name:WILCOXSON, JACQUELINE L (PHD, LMFT)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:L
Last Name:WILCOXSON
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6809 INDIANA AVE
Mailing Address - Street 2:#130-A21
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506
Mailing Address - Country:US
Mailing Address - Phone:424-354-6825
Mailing Address - Fax:
Practice Address - Street 1:6809 INDIANA AVE
Practice Address - Street 2:#130-A21
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:424-354-6825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-10
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC32354106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist