Healthcare Provider Details

I. General information

NPI: 1205959277
Provider Name (Legal Business Name): JAQUELINE MEJIA CERTIFICATE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 NEOTOMAS AVE
SANTA ROSA CA
95405-7575
US

IV. Provider business mailing address

1916 GENOA PL
SANTA ROSA CA
95403-1892
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-7670
  • Fax:
Mailing address:
  • Phone: 707-480-2602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAII055080418
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: