Healthcare Provider Details

I. General information

NPI: 1225158033
Provider Name (Legal Business Name): JACQUELINE NICOLE HURT-COPPOLA MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10098 JIBBOOM ST STE 101
TRUCKEE CA
96161-0287
US

IV. Provider business mailing address

10098 JIBBOOM ST STE 101
TRUCKEE CA
96161-0287
US

V. Phone/Fax

Practice location:
  • Phone: 775-223-6035
  • Fax:
Mailing address:
  • Phone: 530-448-6985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number01085
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 52889
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: