Provider Demographics
NPI:1285861534
Name:LONGTIN, JEANNETTE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:JEANNETTE
Middle Name:
Last Name:LONGTIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 BLOSSOM DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-5213
Mailing Address - Country:US
Mailing Address - Phone:415-785-7142
Mailing Address - Fax:415-485-1571
Practice Address - Street 1:905 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1588
Practice Address - Country:US
Practice Address - Phone:415-785-7142
Practice Address - Fax:745-485-1571
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-14
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC20579106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist