Healthcare Provider Details

I. General information

NPI: 1639551856
Provider Name (Legal Business Name): JEANETTE KAY LASATER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 W F ST
OAKDALE CA
95361-3734
US

IV. Provider business mailing address

PO BOX 238
COLUMBIA CA
95310-0238
US

V. Phone/Fax

Practice location:
  • Phone: 209-288-2682
  • Fax: 209-288-2682
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberLMFT40853
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberLMFT40853
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberLMFT40853
License Number StateCA

VIII. Authorized Official

Name: JEANETTE KAY LASATER
Title or Position: LICENSEDMARRIAGE & FAMILY THERAPIST
Credential: LMFT
Phone: 209-288-2682