Provider Demographics
NPI:1306223789
Name:SMITH, MARY JANE (RN, PHN, LMFT)
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN, PHN, LMFT
Other - Prefix:
Other - First Name:MARY JANE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:610 D ST STE C
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3708
Mailing Address - Country:US
Mailing Address - Phone:415-827-2974
Mailing Address - Fax:
Practice Address - Street 1:610 D ST STE C
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901
Practice Address - Country:US
Practice Address - Phone:415-827-2974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT35490106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist