Provider Demographics
NPI:1790163111
Name:ANDERSON, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2063 ASCOT DR
Mailing Address - Street 2:UNIT 216
Mailing Address - City:MORAGA
Mailing Address - State:CA
Mailing Address - Zip Code:94556-2264
Mailing Address - Country:US
Mailing Address - Phone:925-377-0696
Mailing Address - Fax:
Practice Address - Street 1:2920 CAMINO DIABLO
Practice Address - Street 2:#200
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-3985
Practice Address - Country:US
Practice Address - Phone:925-268-8205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96375106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist