Provider Demographics
NPI:1154539310
Name:JEALOUS, ANN TODD (LMFT)
Entity type:Individual
Prefix:MS
First Name:ANN
Middle Name:TODD
Last Name:JEALOUS
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 1:488 GIBSON AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFIC GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:93950-4416
Mailing Address - Country:US
Mailing Address - Phone:831-644-9404
Mailing Address - Fax:
Practice Address - Street 1:311 FOREST AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:PACIFIC GROVE
Practice Address - State:CA
Practice Address - Zip Code:93950-3367
Practice Address - Country:US
Practice Address - Phone:831-644-9404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC15923106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC15923OtherFAMILY THERAPIST