=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902114523
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAIME NISENBAUM PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2010
-----------------------------------------------------
Last Update Date | 09/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 D ST STE 201
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-516-0797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 LONGVIEW AVE
-----------------------------------------------------
City | SAN ANSELMO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94960-2325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-516-0797
-----------------------------------------------------
Fax | 415-456-2291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY 23623
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY 23623
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | PSY 23623
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------