Provider Demographics
NPI:1285405183
Name:CHAVEZ, JESSE ALEXANDER
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:ALEXANDER
Last Name:CHAVEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131B STONY CIRCLE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401
Mailing Address - Country:US
Mailing Address - Phone:707-576-7700
Mailing Address - Fax:
Practice Address - Street 1:131B STONY CIRCLE
Practice Address - Street 2:SUITE 1200
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401
Practice Address - Country:US
Practice Address - Phone:707-576-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA153281106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program