Provider Demographics
NPI:1811299563
Name:BASARICH, JENNIE LEE (LMFT)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:LEE
Last Name:BASARICH
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 1:327 COLLEGE ST STE 212
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-3484
Mailing Address - Country:US
Mailing Address - Phone:707-477-8957
Mailing Address - Fax:530-402-1622
Practice Address - Street 1:327 COLLEGE ST STE 212
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695
Practice Address - Country:US
Practice Address - Phone:707-477-8957
Practice Address - Fax:530-402-1622
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-01
Last Update Date:2018-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53333106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist