MEDICARE: JACQUELINE GRAVELL-O'KANE LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	IMF66104	CA
2	106H00000X	Marriage & Family Therapist	82565	CA

General Provider Information

NPI Number	:	1194015446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE GRAVELL-O'KANE LMFT

Provider Business Mailing Address
First Line	:	28241 CROWN VALLEY PKWY # F162
Second Line	:
City	:	LAGUNA NIGUEL
State	:	CA
Zip	:	92677-4441
Country	:	US
Telephone Number	:	562-598-2577
Fax Number	:

Provider Business Practice Location Address
First Line	:	28241 CROWN VALLEY PKWY # F162
Second Line	:
City	:	LAGUNA NIGUEL
State	:	CA
Zip	:	92677-4441
Country	:	US
Telephone Number	:	562-598-2577
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2011
Last Update Date	:	05/22/2024

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