Provider Demographics
NPI:1457487571
Name:HOLMES, JACQUELYN LEE (MFT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:LEE
Last Name:HOLMES
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1868 CLAYTON RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-2547
Mailing Address - Country:US
Mailing Address - Phone:925-682-4891
Mailing Address - Fax:925-682-5535
Practice Address - Street 1:1868 CLAYTON RD
Practice Address - Street 2:SUITE 230
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2547
Practice Address - Country:US
Practice Address - Phone:925-682-4891
Practice Address - Fax:925-682-5535
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC25575106H00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist