Healthcare Provider Details

I. General information

NPI: 1871887109
Provider Name (Legal Business Name): JO ELLA COLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 05/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 CHANATE RD
SANTA ROSA CA
95404-1708
US

IV. Provider business mailing address

3322 CHANATE RD
SANTA ROSA CA
95404-1708
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-4797
  • Fax: 707-565-4907
Mailing address:
  • Phone: 707-565-4797
  • Fax: 707-565-4907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number88067
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: