Provider Demographics
NPI:1336878719
Name:CONTRERAS, JAQUELINE
Entity Type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:
Last Name:CONTRERAS
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 1:2389 ROSE LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93012-9023
Mailing Address - Country:US
Mailing Address - Phone:805-832-0785
Mailing Address - Fax:
Practice Address - Street 1:125 W THOUSAND OAKS BLVD STE 600
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4463
Practice Address - Country:US
Practice Address - Phone:805-777-3505
Practice Address - Fax:805-777-3574
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136352106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist