Provider Demographics
NPI:1043088164
Name:FORAKER, AMY JULAINE (LPCC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JULAINE
Last Name:FORAKER
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 BRIERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:IONE
Mailing Address - State:CA
Mailing Address - Zip Code:95640-5207
Mailing Address - Country:US
Mailing Address - Phone:209-256-1542
Mailing Address - Fax:
Practice Address - Street 1:1001 BROADWAY STE 104
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2649
Practice Address - Country:US
Practice Address - Phone:209-256-1542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12728101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional