Healthcare Provider Details

I. General information

NPI: 1184214876
Provider Name (Legal Business Name): JEANNIE LEILANI YEAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3108 W HAMMER LN STE B
STOCKTON CA
95209-2752
US

IV. Provider business mailing address

PO BOX 2394
MANTECA CA
95336-1163
US

V. Phone/Fax

Practice location:
  • Phone: 209-403-4269
  • Fax:
Mailing address:
  • Phone: 209-403-4269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC15154
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: