Provider Demographics
NPI:1447027628
Name:TAGUE, JILLIAN LEIGH (MA, EDS)
Entity type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:LEIGH
Last Name:TAGUE
Suffix:
Gender:M
Credentials:MA, EDS
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:LEIGH
Other - Last Name:MALCZYNSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8882 BELLSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-4615
Mailing Address - Country:US
Mailing Address - Phone:714-330-8277
Mailing Address - Fax:
Practice Address - Street 1:8882 BELLSHIRE DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-4615
Practice Address - Country:US
Practice Address - Phone:714-330-8277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4437103T00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool