Provider Demographics
NPI:1407918774
Name:ROSENBERG, JILL LAUREN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:LAUREN
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 CLARK WAY
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-2300
Mailing Address - Country:US
Mailing Address - Phone:650-617-3873
Mailing Address - Fax:650-322-4329
Practice Address - Street 1:650 CLARK WAY
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2300
Practice Address - Country:US
Practice Address - Phone:650-617-3873
Practice Address - Fax:650-322-4329
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 21005103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical