Provider Demographics
NPI:1295568483
Name:VAN BUREN, JACQUELYN ANETTE (RADT)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ANETTE
Last Name:VAN BUREN
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6293
Mailing Address - Country:US
Mailing Address - Phone:707-718-4872
Mailing Address - Fax:
Practice Address - Street 1:1234 TRAVIS BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4802
Practice Address - Country:US
Practice Address - Phone:707-718-4872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1568820724101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)