MEDICARE: MS. JEAN E. CANTRELL M.F.T.

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	106H00000X	Marriage & Family Therapist	40401	CA

General Provider Information

NPI Number	:	1952511032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JEAN E. CANTRELL M.F.T.

Provider Business Mailing Address
First Line	:	225 MAYHEW WAY APT 13
Second Line	:
City	:	WALNUT CREEK
State	:	CA
Zip	:	94597-2180
Country	:	US
Telephone Number	:	925-935-8686
Fax Number	:

Provider Business Practice Location Address
First Line	:	2551 SAN PABLO AVE
Second Line	:	SUITE 222
City	:	OAKLAND
State	:	CA
Zip	:	94612-1159
Country	:	US
Telephone Number	:	510-446-7124
Fax Number	:	510-268-0550

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/08/2007

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