MEDICARE: JACQUELINE DE MARIA MCP

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	106H00000X	Marriage & Family Therapist	IMF80356	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IMF80356	OTHER	CA	BOARD OF BEHAVIORAL SCIENCES

General Provider Information

NPI Number	:	1588035778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE DE MARIA MCP

Provider Business Mailing Address
First Line	:	2930 W 7TH ST APT 10
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90005-3953
Country	:	US
Telephone Number	:	213-610-3001
Fax Number	:

Provider Business Practice Location Address
First Line	:	2930 W 7TH ST APT 10
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90005-3953
Country	:	US
Telephone Number	:	213-610-3001
Fax Number	:

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

Provider Enumeration Date	:	10/13/2015
Last Update Date	:	10/13/2015

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