Provider Demographics
NPI:1043886187
Name:EPPINGER, JACQUELINE M
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:EPPINGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:EPPINGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:10866 1/2 BLIX ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602-1353
Mailing Address - Country:US
Mailing Address - Phone:410-693-4061
Mailing Address - Fax:
Practice Address - Street 1:3123 SE 31ST AVE APT A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1981
Practice Address - Country:US
Practice Address - Phone:410-693-4061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-30
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122751101YM0800X
CA147207106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health