Provider Demographics
NPI:1356414312
Name:BURNETT, JEAN W (MFT 6909)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:W
Last Name:BURNETT
Suffix:
Gender:F
Credentials:MFT 6909
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 D ST STE 203
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901
Mailing Address - Country:US
Mailing Address - Phone:415-456-6523
Mailing Address - Fax:415-456-6599
Practice Address - Street 1:711 D ST STE 203
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:415-456-6523
Practice Address - Fax:415-456-6599
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFT 6909106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist