MEDICARE: DR. JACQUELINE D BROCK LMFT

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	47723	CA

General Provider Information

NPI Number	:	1780905000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUELINE D BROCK LMFT

Provider Business Mailing Address
First Line	:	760 N EUCLID ST
Second Line	:	SUITE 108
City	:	ANAHEIM
State	:	CA
Zip	:	92801-4133
Country	:	US
Telephone Number	:	323-893-5522
Fax Number	:	323-728-3911

Provider Business Practice Location Address
First Line	:	760 N EUCLID ST
Second Line	:	SUITE 108
City	:	ANAHEIM
State	:	CA
Zip	:	92801-4133
Country	:	US
Telephone Number	:	323-893-5522
Fax Number	:	323-728-3911

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

Provider Enumeration Date	:	06/21/2010
Last Update Date	:	06/21/2010

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