Provider Demographics
NPI:1871133462
Name:BOEHLKE, JENNIFER (LMFT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BOEHLKE
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 1:25A MOREHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:LA SELVA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:95076-1628
Mailing Address - Country:US
Mailing Address - Phone:408-673-8244
Mailing Address - Fax:
Practice Address - Street 1:25A MOREHOUSE DR
Practice Address - Street 2:
Practice Address - City:LA SELVA BEACH
Practice Address - State:CA
Practice Address - Zip Code:95076-1628
Practice Address - Country:US
Practice Address - Phone:408-673-8244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT116652106H00000X
CALMFT129227106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist