Provider Demographics
NPI:1528173317
Name:REYNOLDS, JEANA LUREE (MFT)
Entity type:Individual
Prefix:
First Name:JEANA
Middle Name:LUREE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 LINCOLN AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2120
Mailing Address - Country:US
Mailing Address - Phone:415-606-1166
Mailing Address - Fax:
Practice Address - Street 1:1330 LINCOLN AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2120
Practice Address - Country:US
Practice Address - Phone:415-606-1166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC34872106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist