Healthcare Provider Details

I. General information

NPI: 1942456694
Provider Name (Legal Business Name): JACLYN K DOUGLASS M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 S GERONIMO RD
APACHE JUNCTION AZ
85219-9830
US

IV. Provider business mailing address

1240 S GERONIMO RD
APACHE JUNCTION AZ
85219-9830
US

V. Phone/Fax

Practice location:
  • Phone: 480-495-6946
  • Fax:
Mailing address:
  • Phone: 480-495-6946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: