Healthcare Provider Details

I. General information

NPI: 1992600258
Provider Name (Legal Business Name): JACQUELINE BRUBAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8258 NORTON AVE APT 3
WEST HOLLYWOOD CA
90046-5935
US

IV. Provider business mailing address

8258 NORTON AVE APT 3
WEST HOLLYWOOD CA
90046-5935
US

V. Phone/Fax

Practice location:
  • Phone: 818-399-1030
  • Fax:
Mailing address:
  • Phone: 818-399-1030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164456
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: