Healthcare Provider Details

I. General information

NPI: 1285405183
Provider Name (Legal Business Name): JESSE ALEXANDER CHAVEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2024
Last Update Date: 04/10/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131B STONY CIRCLE SUITE 1200
SANTA ROSA CA
95401
US

IV. Provider business mailing address

131B STONY CIRCLE SUITE 1200
SANTA ROSA CA
95401
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-7700
  • Fax:
Mailing address:
  • Phone: 707-576-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number153281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: