Provider Demographics
NPI:1114156312
Name:JAMESON, ROBERT CARROLL (MFT)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CARROLL
Last Name:JAMESON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1828 1/2 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2810
Mailing Address - Country:US
Mailing Address - Phone:310-395-7047
Mailing Address - Fax:
Practice Address - Street 1:1828 1/2 BROADWAY
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2810
Practice Address - Country:US
Practice Address - Phone:310-395-7047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC22984106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist