Provider Demographics
NPI:1336732114
Name:JAUREQUI, MATTHEW (LMFT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JAUREQUI
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3816 PETALUMA AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-2447
Mailing Address - Country:US
Mailing Address - Phone:951-970-3185
Mailing Address - Fax:
Practice Address - Street 1:325 JOHN KNOX RD BLDG T
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-4113
Practice Address - Country:US
Practice Address - Phone:850-427-5274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3805106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist