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General NPI Number Information
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NPI Number | 1174682009
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Entity Type | Individual
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Provider Name | MS. JACKIE LYNN BUSTAMANTE
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Gender | Female
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 04/20/2011
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Provider Practice Location Address
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Address Line | 1716 CLARK AVE STE 109
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City | LONG BEACH
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State | CA
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Zip | 90815-3801
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Country | US
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Telephone | 562-706-1072
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Fax |
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Provider Business Mailing Address
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Address Line | 1716 CLARK AVE # 109
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City | LONG BEACH
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State | CA
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Zip | 90815-3801
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Country | US
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Telephone | 562-706-1072
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Fax | 866-678-7357
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 30317
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License Number State | CA
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