MEDICARE: JEANNINE MARDI DALEO 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	MFC38634	CA

General Provider Information

NPI Number	:	1780625160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANNINE MARDI DALEO MFT

Provider Business Mailing Address
First Line	:	3554 ROUND BARN BLVD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-0929
Country	:	US
Telephone Number	:	619-528-4600
Fax Number	:	619-528-4625

Provider Business Practice Location Address
First Line	:	4700 SPRING ST
Second Line	:	STE 220
City	:	LA MESA
State	:	CA
Zip	:	91942-0263
Country	:	US
Telephone Number	:	619-667-3380
Fax Number	:	619-667-0815

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

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	01/11/2022

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