Provider Demographics
NPI:1871065961
Name:LONG, JACLYN (MFT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3156
Mailing Address - Street 2:
Mailing Address - City:HALF MOON BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94019-3156
Mailing Address - Country:US
Mailing Address - Phone:415-533-8012
Mailing Address - Fax:
Practice Address - Street 1:851 FREMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-5698
Practice Address - Country:US
Practice Address - Phone:650-297-3400
Practice Address - Fax:650-897-1005
Is Sole Proprietor?:No
Enumeration Date:2018-12-30
Last Update Date:2023-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47100106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist