Provider Demographics
NPI:1770868069
Name:KEHOE-JERGENS, SUSAN L (LMFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:KEHOE-JERGENS
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 2077
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-2077
Mailing Address - Country:US
Mailing Address - Phone:707-467-2010
Mailing Address - Fax:
Practice Address - Street 1:160 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5017
Practice Address - Country:US
Practice Address - Phone:707-467-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37217171M00000X
CAMFC37217106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator