Provider Demographics
NPI:1245676063
Name:ROSE, JANELLE (LMFT)
Entity type:Individual
Prefix:
First Name:JANELLE
Middle Name:
Last Name:ROSE
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 1:1234 EMPIRE ST STE 1500
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-5711
Mailing Address - Country:US
Mailing Address - Phone:510-849-7477
Mailing Address - Fax:
Practice Address - Street 1:470 CHADBOURNE RD
Practice Address - Street 2:SUITE E
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534
Practice Address - Country:US
Practice Address - Phone:707-425-9670
Practice Address - Fax:707-425-9880
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112405106H00000X
CA81176101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist