Provider Demographics
NPI:1174181960
Name:COOPER, JACQUELINE SUSAN (LMFT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SUSAN
Last Name:COOPER
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 1:833 YORK ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-6252
Mailing Address - Country:US
Mailing Address - Phone:108-652-6085
Mailing Address - Fax:
Practice Address - Street 1:2545 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1121
Practice Address - Country:US
Practice Address - Phone:510-446-7160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA150556106H00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)