Provider Demographics
NPI:1184214876
Name:YEAGER, JEANNIE LEILANI
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:LEILANI
Last Name:YEAGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2394
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-1163
Mailing Address - Country:US
Mailing Address - Phone:209-403-4269
Mailing Address - Fax:
Practice Address - Street 1:3108 W HAMMER LN STE B
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-2752
Practice Address - Country:US
Practice Address - Phone:209-403-4269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALPCC15154101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health