MEDICARE: JEAN CLINTON LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	13052	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	99999999	OTHER		HEALTH NET

General Provider Information

NPI Number	:	1548770092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEAN CLINTON LPC

Provider Business Mailing Address
First Line	:	2370 KERNER BLVD
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-5546
Country	:	US
Telephone Number	:	602-376-8554
Fax Number	:

Provider Business Practice Location Address
First Line	:	2370 KERNER BLVD
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-5546
Country	:	US
Telephone Number	:	602-376-8554
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2017
Last Update Date	:	06/16/2018

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