Provider Demographics
NPI:1437376464
Name:DEKRUSE, JET LOUISE
Entity Type:Individual
Prefix:MS
First Name:JET
Middle Name:LOUISE
Last Name:DEKRUSE
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 1:221 RUSSELL LN
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-9292
Mailing Address - Country:US
Mailing Address - Phone:707-822-3942
Mailing Address - Fax:
Practice Address - Street 1:720 WOOD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4413
Practice Address - Country:US
Practice Address - Phone:707-268-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC22590106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist