Provider Demographics
NPI:1114674850
Name:JAFFE, MARILYN LEE
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:LEE
Last Name:JAFFE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 WEST ST
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2105
Mailing Address - Country:US
Mailing Address - Phone:707-318-3912
Mailing Address - Fax:
Practice Address - Street 1:508 WEST ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2105
Practice Address - Country:US
Practice Address - Phone:707-318-3912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical