MEDICARE: JERALDINE ROBERTSON MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC 34817	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MFC 34817	OTHER	CA	MFT LICENSE

General Provider Information

NPI Number	:	1194931733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERALDINE ROBERTSON MFT

Provider Business Mailing Address
First Line	:	6355 TELEGRAPH AVE
Second Line	:	SUITE 309
City	:	OAKLAND
State	:	CA
Zip	:	94609-1371
Country	:	US
Telephone Number	:	510-282-4644
Fax Number	:	510-533-5968

Provider Business Practice Location Address
First Line	:	6355 TELEGRAPH AVE
Second Line	:	SUITE 309
City	:	OAKLAND
State	:	CA
Zip	:	94609-1371
Country	:	US
Telephone Number	:	510-282-4644
Fax Number	:	510-533-5968

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	07/08/2007

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