=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023677705
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IAIN RENE JASKO MA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2019
-----------------------------------------------------
Last Update Date | 10/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 D ST STE 209
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-621-3644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 711 D ST STE 209
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-621-3644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 158787
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------