Healthcare Provider Details

I. General information

NPI: 1720100902
Provider Name (Legal Business Name): DIANE EUGENIA JANSSEN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 ALPINE BLVD STE 3
ALPINE CA
91901
US

IV. Provider business mailing address

PO BOX 250
DESCANSO CA
91916-0250
US

V. Phone/Fax

Practice location:
  • Phone: 619-933-3957
  • Fax: 619-445-3171
Mailing address:
  • Phone: 619-933-3957
  • Fax: 619-445-3171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC30395
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: