Healthcare Provider Details

I. General information

NPI: 1164544698
Provider Name (Legal Business Name): JEROLD ROSENTHAL M.F.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

2020 COFFEE RD H-6
MODESTO CA
95355-2427
US

IV. Provider business mailing address

2020 COFFEE RD SUITE H-6
MODESTO CA
95355-2427
US

V. Phone/Fax

Practice location:
  • Phone: 209-522-6246
  • Fax: 209-522-0585
Mailing address:
  • Phone: 209-522-6246
  • Fax: 209-522-0585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC31748
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: