Healthcare Provider Details

I. General information

NPI: 1366905051
Provider Name (Legal Business Name): MARC JAY PEDERSEN AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 10/02/2026
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 PROFESSIONAL DR STE 101
SANTA ROSA CA
95403-3007
US

IV. Provider business mailing address

16225 RIO NIDO RD
GUERNEVILLE CA
95446-9567
US

V. Phone/Fax

Practice location:
  • Phone: 707-544-3295
  • Fax:
Mailing address:
  • Phone: 707-292-3010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164756
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: