Provider Demographics
NPI:1447853080
Name:VANDERJAGT, MICHELLE (LMFT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:VANDERJAGT
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 1:912 TUCANA DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-2827
Mailing Address - Country:US
Mailing Address - Phone:925-658-8367
Mailing Address - Fax:
Practice Address - Street 1:169 SAXONY RD STE 111
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-6779
Practice Address - Country:US
Practice Address - Phone:760-410-8096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA119382106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist