Healthcare Provider Details

I. General information

NPI: 1093582421
Provider Name (Legal Business Name): JAMIE TENNILLE WEAVER LICENSED MIDWIFE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2023
Last Update Date: 06/08/2024
Certification Date: 06/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4859 OLD REDWOOD HWY
SANTA ROSA CA
95403-1415
US

IV. Provider business mailing address

11900 HWY 116
GUERNEVILLE CA
95446-9479
US

V. Phone/Fax

Practice location:
  • Phone: 740-590-9449
  • Fax:
Mailing address:
  • Phone: 740-590-9449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: