Healthcare Provider Details

I. General information

NPI: 1114654571
Provider Name (Legal Business Name): MS. JULYANA DENAE JACOBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. JULIYANA DENAE JACOBS

II. Dates (important events)

Enumeration Date: 08/05/2022
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1143 MISSOURI ST
FAIRFIELD CA
94533-6007
US

IV. Provider business mailing address

1143 MISSOURI ST
FAIRFIELD CA
94533-6007
US

V. Phone/Fax

Practice location:
  • Phone: 707-435-9911
  • Fax:
Mailing address:
  • Phone: 707-435-9911
  • Fax: 707-435-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1490251122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: