MEDICARE: JAMIE TENNILLE WEAVER LICENSED MIDWIFE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374J00000X	Doula
2	176B00000X	Midwife	717	CA

General Provider Information

NPI Number	:	1093582421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMIE TENNILLE WEAVER LICENSED MIDWIFE

Provider Business Mailing Address
First Line	:	11900 HWY 116
Second Line	:
City	:	GUERNEVILLE
State	:	CA
Zip	:	95446-9479
Country	:	US
Telephone Number	:	740-590-9449
Fax Number	:

Provider Business Practice Location Address
First Line	:	4859 OLD REDWOOD HWY
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-1415
Country	:	US
Telephone Number	:	740-590-9449
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2023
Last Update Date	:	06/08/2024

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