Healthcare Provider Details

I. General information

NPI: 1093213159
Provider Name (Legal Business Name): JACQUELINE SARAH ROBERTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4129 STATE ST
SANTA BARBARA CA
93110-1848
US

IV. Provider business mailing address

516 BRAEMAR RANCH LN
SANTA BARBARA CA
93109-1064
US

V. Phone/Fax

Practice location:
  • Phone: 805-964-4795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF101329
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: