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General NPI Number Information
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NPI Number | 1346892999
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Entity Type | Individual
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Provider Name | MATTHEW LUDWIG JANSE LMFT
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Gender | Male
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Dates
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Enumeration Date | 07/14/2019
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Last Update Date | 07/14/2019
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Provider Practice Location Address
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Address Line | 10685 MAGNOLIA AVE
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City | RIVERSIDE
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State | CA
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Zip | 92505-1822
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Country | US
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Telephone | 909-276-7113
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Fax |
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Provider Business Mailing Address
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Address Line | 10935 TERRA VISTA PKWY APT 182
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-6356
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Country | US
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Telephone | 909-282-0038
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 102378
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License Number State | CA
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