Healthcare Provider Details

I. General information

NPI: 1154051191
Provider Name (Legal Business Name): MAYA CLOTILDE JACOBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 ESTUDILLO AVE STE 100
SAN LEANDRO CA
94577-4962
US

IV. Provider business mailing address

1700 MARKET ST
OAKLAND CA
94607-3330
US

V. Phone/Fax

Practice location:
  • Phone: 510-924-0548
  • Fax:
Mailing address:
  • Phone: 510-543-0078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number141610
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: