Provider Demographics
NPI:1548570583
Name:COUSINEAU, JACK SHIELDS (LMFT)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:SHIELDS
Last Name:COUSINEAU
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 697
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94543-0697
Mailing Address - Country:US
Mailing Address - Phone:626-710-7915
Mailing Address - Fax:855-647-5562
Practice Address - Street 1:3700 DELTA FAIR BLVD STE 201A
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4073
Practice Address - Country:US
Practice Address - Phone:510-809-7350
Practice Address - Fax:855-647-5562
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT90191106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist