Active NPI
Jackie A Provencher, AMFT
- Marriage & Family Therapist
- Long Beach, CA
National Provider Identifier
1497397939
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Marriage & Family Therapist
- License
- 79380
- Practice address
- 2211 E Ocean Blvd
Long Beach, CA 90803-2440 - Phone
- (562) 434-4060
- NPI assigned
- Oct 16, 2019
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Marriage & Family Therapist | 106H00000X | 79380 | CA | Primary |
Addresses
Primary practice location
2211 E Ocean Blvd
Long Beach, CA 90803-2440
Mailing address
7025 E El Paseo St
Long Beach, CA 90815-3507
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 79380 | Other | CA | MARRIAGE AND FAMILY THERAPIST ASSOCIATE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 79380 | CA | MD | Marriage & Family Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1571184000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1571184000000",
"number": "1497397939",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "7025 E EL PASEO ST",
"city": "LONG BEACH",
"state": "CA",
"postal_code": "908153507"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2211 E OCEAN BLVD",
"city": "LONG BEACH",
"state": "CA",
"postal_code": "908032440",
"telephone_number": "562-434-4060"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PROVENCHER",
"first_name": "JACKIE",
"middle_name": "A",
"name_prefix": "Ms.",
"credential": "AMFT",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2019-10-16",
"last_updated": "2019-10-16",
"status": "A"
},
"taxonomies": [
{
"code": "106H00000X",
"taxonomy_group": "",
"desc": "Marriage & Family Therapist",
"state": "CA",
"license": "79380",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MARRIAGE AND FAMILY THERAPIST ASSOCIATE",
"identifier": "79380",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Long Beach, CA
- Proprius Health Medical Group PC
- Prospect Family Therapy, a Professional Corporation
- Prospective Healthcare Solutions
- Prospective Vision Optometric Corp
- Stacey L Prothro, LCSW
- Provia Psychology, Inc.
- Prudent Comfort Homes Inc
- Roshawon Latice Pruitt, AA, DSP I
- Kunthy Prum, MD
- Pruss Chiropractic Corproation
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 16, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.