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General NPI Number Information
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NPI Number | 1164228490
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Entity Type | Individual
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Provider Name | JACQUELINE VAN PHAM
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Gender |
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Dates
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Enumeration Date | 02/19/2025
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Last Update Date | 02/19/2025
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Provider Practice Location Address
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Address Line | 613 OCEAN PARK BLVD
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City | SANTA MONICA
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State | CA
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Zip | 90405-3713
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Country | US
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Telephone | 206-841-6561
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Fax |
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Provider Business Mailing Address
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Address Line | 3980 WILSHIRE BLVD APT 222
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City | LOS ANGELES
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State | CA
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Zip | 90010-4214
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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