Provider Demographics
NPI:1750719480
Name:MACE, JEREMY LEE (LCSW)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:LEE
Last Name:MACE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 DOWDELL AVE UNIT 143
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-4124
Mailing Address - Country:US
Mailing Address - Phone:262-290-6529
Mailing Address - Fax:
Practice Address - Street 1:475-750 RICE CANYON ROAD
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96127
Practice Address - Country:US
Practice Address - Phone:530-251-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI129074-1211041C0700X
CALCSW740141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3411849631Medicaid