Healthcare Provider Details

I. General information

NPI: 1336732114
Provider Name (Legal Business Name): MATTHEW JAUREQUI LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3816 PETALUMA AVE
LONG BEACH CA
90808-2447
US

IV. Provider business mailing address

3816 PETALUMA AVE
LONG BEACH CA
90808-2447
US

V. Phone/Fax

Practice location:
  • Phone: 850-391-8070
  • Fax:
Mailing address:
  • Phone: 951-970-3185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT.0002002
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT3805
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT131002
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: