Healthcare Provider Details

I. General information

NPI: 1891162855
Provider Name (Legal Business Name): JENNA ROAT MFTINTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5297 COLLEGE AVE
OAKLAND CA
94618-1462
US

IV. Provider business mailing address

45 CARL ST
SAN FRANCISCO CA
94117-3917
US

V. Phone/Fax

Practice location:
  • Phone: 510-898-6553
  • Fax:
Mailing address:
  • Phone: 415-969-1512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number#IMF84180
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: