Provider Demographics
NPI:1801272448
Name:STARKS, JENNIFER LEE (LMFT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:STARKS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19663 MOUNTAIN HOUSE PKWY STE 333
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOUSE
Mailing Address - State:CA
Mailing Address - Zip Code:95391-8042
Mailing Address - Country:US
Mailing Address - Phone:209-222-8802
Mailing Address - Fax:209-255-4536
Practice Address - Street 1:403 W 11TH ST STE A
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3816
Practice Address - Country:US
Practice Address - Phone:209-222-8802
Practice Address - Fax:209-255-4536
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT101980101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1628542Medicaid