Healthcare Provider Details

I. General information

NPI: 1033398615
Provider Name (Legal Business Name): JENELLE ALYCE OKKERSE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 D ST
MARYSVILLE CA
95901-6017
US

IV. Provider business mailing address

159 BRENTWOOD DR
GRASS VALLEY CA
95945-5703
US

V. Phone/Fax

Practice location:
  • Phone: 916-705-1854
  • Fax:
Mailing address:
  • Phone: 530-273-9541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number84317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: