Basic Information
| Provider Information | |||||||||
| NPI: | 1083212542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDSEADEL | ||||||||
| FirstName: | JAIMIE | ||||||||
| MiddleName: | R. | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | LANDSEADEL | ||||||||
| OtherFirstName: | JAIMIE | ||||||||
| OtherMiddleName: | R. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3433 W SHAW AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937113229 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2934 N FRESNO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937031123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595584051 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2020 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.