Provider Demographics
NPI:1114205192
Name:RADKE, JAN (MA, MFT,)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:RADKE
Suffix:
Gender:F
Credentials:MA, MFT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1654 HOPPER AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-8600
Mailing Address - Country:US
Mailing Address - Phone:707-526-6947
Mailing Address - Fax:
Practice Address - Street 1:1023 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4112
Practice Address - Country:US
Practice Address - Phone:707-486-0306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT20457106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT20457OtherMARRIAGE AND FAMILY COUNSELING LICENSE