Provider Demographics
NPI:1396305454
Name:LAVENDER, JAMIE (LMFT)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:LAVENDER
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 BRIGGS AVE APT F
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4849
Mailing Address - Country:US
Mailing Address - Phone:415-723-0563
Mailing Address - Fax:
Practice Address - Street 1:3250 BRIGGS AVE APT F
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4849
Practice Address - Country:US
Practice Address - Phone:415-723-0563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48973106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist