Provider Demographics
NPI:1629524392
Name:BEKAERT, JILL A (MFT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:BEKAERT
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 1:1008 MCCLOUD AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-9606
Mailing Address - Country:US
Mailing Address - Phone:530-925-1597
Mailing Address - Fax:
Practice Address - Street 1:301 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2214
Practice Address - Country:US
Practice Address - Phone:530-926-1436
Practice Address - Fax:530-926-2305
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT110796106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist