Provider Demographics
NPI:1649368150
Name:LANGSTON, JAIN FAIRFAX (LMFT)
Entity type:Individual
Prefix:MRS
First Name:JAIN
Middle Name:FAIRFAX
Last Name:LANGSTON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:DR
Other - First Name:JAIN
Other - Middle Name:
Other - Last Name:FAIRFAX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD LMFT
Mailing Address - Street 1:2455 BENNETT VALLEY RD
Mailing Address - Street 2:SUITE B-208
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5663
Mailing Address - Country:US
Mailing Address - Phone:707-526-2580
Mailing Address - Fax:707-526-2580
Practice Address - Street 1:2455 BENNETT VALLEY RD
Practice Address - Street 2:SUITE B-208
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5663
Practice Address - Country:US
Practice Address - Phone:707-526-2580
Practice Address - Fax:707-526-2580
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 25636106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist