Provider Demographics
NPI:1073642716
Name:CHESLEY, JILLIAN KERRY (MFT)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:KERRY
Last Name:CHESLEY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 PELTON AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-6414
Mailing Address - Country:US
Mailing Address - Phone:831-331-0081
Mailing Address - Fax:
Practice Address - Street 1:111 ERRETT CIR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-5920
Practice Address - Country:US
Practice Address - Phone:831-331-0081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF46777106H00000X
CA46156106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8659OtherMEDICAL PROVIDER STAFF ID