=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083415632
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANE MEDEMA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2025
-----------------------------------------------------
Last Update Date | 03/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 N SAINT PAUL ST STE 3100
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75201-3923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-992-6155
-----------------------------------------------------
Fax | 650-360-6913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 447 SUTTER ST STE 405
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94108-4618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-992-6155
-----------------------------------------------------
Fax | 650-360-6913
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 98107
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------