Provider Demographics
NPI:1770673584
Name:MEALEY, JEANNINE BLEAM (LMFT)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:BLEAM
Last Name:MEALEY
Suffix:
Gender:F
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 16
Mailing Address - Street 2:
Mailing Address - City:BOULDER CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95006-0016
Mailing Address - Country:US
Mailing Address - Phone:408-364-4009
Mailing Address - Fax:
Practice Address - Street 1:225 37TH AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-4324
Practice Address - Country:US
Practice Address - Phone:650-573-3659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC38405106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4733OtherSCC ID