Healthcare Provider Details

I. General information

NPI: 1366698649
Provider Name (Legal Business Name): JENNIFER DIVERS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 POLK ST
SAN FRANCISCO CA
94102-3333
US

IV. Provider business mailing address

555 POLK ST
SAN FRANCISCO CA
94102-3333
US

V. Phone/Fax

Practice location:
  • Phone: 628-217-6421
  • Fax:
Mailing address:
  • Phone: 628-217-6421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number49654
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: