Healthcare Provider Details

I. General information

NPI: 1396346763
Provider Name (Legal Business Name): JILL K APPLEGATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 11/03/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 STANDISH AVE
SANTA ROSA CA
95407-8113
US

IV. Provider business mailing address

4710 GRANADA DR
SANTA ROSA CA
95409-3011
US

V. Phone/Fax

Practice location:
  • Phone: 707-738-4308
  • Fax:
Mailing address:
  • Phone: 707-738-4308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: