Provider Demographics
NPI:1235638255
Name:DELUCA, JACQUELINE ANDREA (LCSW113846)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANDREA
Last Name:DELUCA
Suffix:
Gender:F
Credentials:LCSW113846
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ANDREA
Other - Last Name:JACQUES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ASW76857
Mailing Address - Street 1:PO BOX 2094
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92690-0094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4470 W SUNSET BLVD STE 107
Practice Address - Street 2:PMB94731
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027
Practice Address - Country:US
Practice Address - Phone:323-968-6182
Practice Address - Fax:833-419-0181
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW76857101YM0800X
103T00000X
CA1138461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist