Provider Demographics
NPI:1093942518
Name:GERRITSEN, JACQUELINE (MA, MFT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:GERRITSEN
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PARK PL APT P
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-7112
Mailing Address - Country:US
Mailing Address - Phone:650-315-7207
Mailing Address - Fax:
Practice Address - Street 1:2875 MIDDLEFIELD RD STE 8
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-2548
Practice Address - Country:US
Practice Address - Phone:650-315-7207
Practice Address - Fax:540-323-2217
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC44948106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist