Provider Demographics
NPI:1235449547
Name:JANSON, NICOLE ERIKA (MFT INTERN)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ERIKA
Last Name:JANSON
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 CANE ST APT 10
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-2079
Mailing Address - Country:US
Mailing Address - Phone:415-786-0950
Mailing Address - Fax:
Practice Address - Street 1:3164 CONDO CT
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2557
Practice Address - Country:US
Practice Address - Phone:707-523-2334
Practice Address - Fax:707-523-0133
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54056106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist