Healthcare Provider Details

I. General information

NPI: 1376945741
Provider Name (Legal Business Name): JACQUELINE DONAHUE PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD MS #53
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

4650 W SUNSET BLVD # 53
LOS ANGELES CA
90027-6062
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-3849
  • Fax:
Mailing address:
  • Phone: 323-361-2489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPSY31339
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number2012897
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY31339
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: