Healthcare Provider Details

I. General information

NPI: 1528049715
Provider Name (Legal Business Name): JEAN ROSENGARTEN DAVIDSON LCSW, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 E COLFAX AVE
SOUTH BEND IN
46617-2827
US

IV. Provider business mailing address

616 E. COLFAX AVENUE
SOUTH BEND IN
46617
US

V. Phone/Fax

Practice location:
  • Phone: 574-261-1255
  • Fax: 574-289-7000
Mailing address:
  • Phone: 812-649-2936
  • Fax: 812-649-2936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34000496A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35000827A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: