Provider Demographics
NPI:1023450301
Name:LAU, JACKY (MFT-INTERN)
Entity type:Individual
Prefix:
First Name:JACKY
Middle Name:
Last Name:LAU
Suffix:
Gender:M
Credentials:MFT-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 25TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-2102
Mailing Address - Country:US
Mailing Address - Phone:619-232-6454
Mailing Address - Fax:619-235-4607
Practice Address - Street 1:1031 25TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2102
Practice Address - Country:US
Practice Address - Phone:619-232-6454
Practice Address - Fax:619-235-4607
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA81955106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program