Provider Demographics
NPI:1639824410
Name:BURNS, JACQUELINE LEIGH
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEIGH
Last Name:BURNS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:LEIGH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6 LAUREL PL APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2168
Mailing Address - Country:US
Mailing Address - Phone:415-378-0993
Mailing Address - Fax:
Practice Address - Street 1:201 ALAMEDA DEL PRADO STE 103
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-6698
Practice Address - Country:US
Practice Address - Phone:415-457-6964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-19
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT138172171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator