Provider Demographics
NPI:1720209117
Name:LEISE, JERI LYNN (MFT)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:LYNN
Last Name:LEISE
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:PO BOX 194
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95402-0194
Mailing Address - Country:US
Mailing Address - Phone:707-486-5570
Mailing Address - Fax:707-579-0809
Practice Address - Street 1:1421 GUERNEVILLE RD
Practice Address - Street 2:SUITE 114
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7220
Practice Address - Country:US
Practice Address - Phone:707-486-5570
Practice Address - Fax:707-579-0809
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC36649106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist