Healthcare Provider Details

I. General information

NPI: 1518303817
Provider Name (Legal Business Name): JEN MARIE LYTLE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2261 ELM STREET, BUILDING P
NAPA CA
94559
US

IV. Provider business mailing address

2261 ELM STREET, BUILDING P
NAPA CA
94559
US

V. Phone/Fax

Practice location:
  • Phone: 707-253-4837
  • Fax: 707-299-4107
Mailing address:
  • Phone: 707-253-4837
  • Fax: 707-299-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12345
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: