Healthcare Provider Details

I. General information

NPI: 1457954430
Provider Name (Legal Business Name): JAQUELYN WEBER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1722
BOULDER CREEK CA
95006-1722
US

IV. Provider business mailing address

PO BOX 1722
BOULDER CREEK CA
95006-1722
US

V. Phone/Fax

Practice location:
  • Phone: 831-226-8949
  • Fax:
Mailing address:
  • Phone: 831-226-8949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164093
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: