Provider Demographics
NPI:1710332770
Name:LANE, JESSICA KEIKO (MFT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KEIKO
Last Name:LANE
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 1:3120 TELEGRAPH AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1900
Mailing Address - Country:US
Mailing Address - Phone:510-527-6188
Mailing Address - Fax:
Practice Address - Street 1:3120 TELEGRAPH AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1900
Practice Address - Country:US
Practice Address - Phone:510-527-6188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT44341106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist