Provider Demographics
NPI:1598911208
Name:PONTES-BOELTER, JEANINE MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:JEANINE
Middle Name:MARIE
Last Name:PONTES-BOELTER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-5294
Mailing Address - Country:US
Mailing Address - Phone:209-535-3501
Mailing Address - Fax:
Practice Address - Street 1:4141 GEARY BLVD
Practice Address - Street 2:4TH FLOOR
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-3109
Practice Address - Country:US
Practice Address - Phone:415-833-2292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-13
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 22084103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY 22084OtherCALIFORNIA BOARD OF PSYCHOLOGY