MEDICARE: JACQUELINE S. BIXBY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	114667	CA

General Provider Information

NPI Number	:	1043860752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE S. BIXBY

Provider Business Mailing Address
First Line	:	6762 LOS VERDES DR APT 2
Second Line	:
City	:	RANCHO PALOS VERDES
State	:	CA
Zip	:	90275-7610
Country	:	US
Telephone Number	:	323-445-4402
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 PACIFIC COAST HWY STE 304A
Second Line	:
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-2702
Country	:	US
Telephone Number	:	323-445-4402
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2019
Last Update Date	:	09/14/2019

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Directions to “ JACQUELINE S. BIXBY ” Practice Location

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