Provider Demographics
NPI:1194842658
Name:CHAVEZ, JEANIE MARIE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:JEANIE
Middle Name:MARIE
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MRS
Other - First Name:JEANIE
Other - Middle Name:MARIE
Other - Last Name:KIELEY-CHAVEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:415 W ROUTE 66 STE 202
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-4335
Mailing Address - Country:US
Mailing Address - Phone:909-860-2166
Mailing Address - Fax:909-963-9543
Practice Address - Street 1:1370 VALLEY VISTA DR
Practice Address - Street 2:SUITE 104
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3911
Practice Address - Country:US
Practice Address - Phone:909-860-2166
Practice Address - Fax:909-963-9543
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39590106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist