Provider Demographics
NPI:1548637283
Name:RADOMSKI, JENNIFER LYNN (MFTI)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:RADOMSKI
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 STANDISH AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-8113
Mailing Address - Country:US
Mailing Address - Phone:707-585-6108
Mailing Address - Fax:707-585-6155
Practice Address - Street 1:3650 STANDISH AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-8113
Practice Address - Country:US
Practice Address - Phone:707-585-6108
Practice Address - Fax:707-585-6155
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFTI 88480101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health