Healthcare Provider Details

I. General information

NPI: 1437955663
Provider Name (Legal Business Name): JENIECE BUTTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2025
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 CAPRICORN WAY STE 207
SANTA ROSA CA
95407-5486
US

IV. Provider business mailing address

2227 CAPRICORN WAY STE 207
SANTA ROSA CA
95407-5486
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-4810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT147326
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: