MEDICARE: JEAN ANNE DOVERSPIKE MFT

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	43837	CA

General Provider Information

NPI Number	:	1942481312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEAN ANNE DOVERSPIKE MFT

Provider Business Mailing Address
First Line	:	3121 PARK AVE
Second Line	:	SUITE I
City	:	SOQUEL
State	:	CA
Zip	:	95073-2920
Country	:	US
Telephone Number	:	831-454-1798
Fax Number	:

Provider Business Practice Location Address
First Line	:	3121 PARK AVE
Second Line	:	SUITE I
City	:	SOQUEL
State	:	CA
Zip	:	95073-2920
Country	:	US
Telephone Number	:	831-454-1798
Fax Number	:

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

Provider Enumeration Date	:	11/14/2007
Last Update Date	:	06/25/2016

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