Healthcare Provider Details

I. General information

NPI: 1710392618
Provider Name (Legal Business Name): JACQUELYN LEWIS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 SHERMAN AVE STE C
PALO ALTO CA
94306-1872
US

IV. Provider business mailing address

P.O. BOX 31373
SAN FRANCISCO CA
94131
US

V. Phone/Fax

Practice location:
  • Phone: 650-461-9026
  • Fax:
Mailing address:
  • Phone: 415-379-0429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number52022
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: