Provider Demographics
NPI:1518613041
Name:LEE, JACLYN (LMFT # 130908)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:LMFT # 130908
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 4TH ST APT 108
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94710-1956
Mailing Address - Country:US
Mailing Address - Phone:415-830-0308
Mailing Address - Fax:
Practice Address - Street 1:2060 4TH ST APT 108
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94710-1956
Practice Address - Country:US
Practice Address - Phone:415-830-0308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA130908106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist