Provider Demographics
NPI:1275881187
Name:AUSTIN, JETAIME N
Entity Type:Individual
Prefix:
First Name:JETAIME
Middle Name:N
Last Name:AUSTIN
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 1:318 W VIENTO ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOUSE
Mailing Address - State:CA
Mailing Address - Zip Code:95391-2064
Mailing Address - Country:US
Mailing Address - Phone:650-942-5245
Mailing Address - Fax:
Practice Address - Street 1:3825 HOPYARD RD # 201
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-8528
Practice Address - Country:US
Practice Address - Phone:925-847-5051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA73269106H00000X
CA92679106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health