Healthcare Provider Details

I. General information

NPI: 1578849022
Provider Name (Legal Business Name): MAXWELL JARED CHURCH CMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2011
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHILDRENS CIR
SANTA ROSA CA
95409-6558
US

IV. Provider business mailing address

100 CHILDRENS CIR
SANTA ROSA CA
95409-6558
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberNONE
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: