Healthcare Provider Details

I. General information

NPI: 1255260170
Provider Name (Legal Business Name): JEROME R CLELAND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 GALLAND ST
PETALUMA CA
94952-2717
US

IV. Provider business mailing address

602 GALLAND ST
PETALUMA CA
94952-2717
US

V. Phone/Fax

Practice location:
  • Phone: 858-205-7578
  • Fax:
Mailing address:
  • Phone: 858-205-7578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: