Provider Demographics
NPI:1376712174
Name:KANE, JOHN MARK
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:KANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 EUREKA RD STE 155
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-7786
Mailing Address - Country:US
Mailing Address - Phone:408-461-9658
Mailing Address - Fax:
Practice Address - Street 1:1700 EUREKA RD STE 155
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7786
Practice Address - Country:US
Practice Address - Phone:408-461-9658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA134414106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist