Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103G00000X | Clinical Psychologist | PSY12143 | CA |
N | 103TC0700X | Clinical Psychologist | PSY12143 | CA |
N | 102L00000X | Psychologist | PSY12143 | CA |
N | 103T00000X | Psychologist | PSY12143 | CA |
Y | 103TA0700X | Adult Development & Aging Psychologist | PSY12143 | CA |
N | 103G00000X | Clinical Psychologist | PSY12143 | CA |
N | 103TC0700X | Clinical Psychologist | PSY12143 | CA |
N | 103TF0200X | Forensic Psychologist | PSY12143 | CA |
N | 103TH0100X | Health Service | PSY12143 | CA |
N | 103TR0400X | Rehabilitation Psychologist | PSY12143 | CA |
NPI | 1154382380 |
---|---|
Provider Name | Dr. Jonathon M Rose |
First Address | San Carlos, CA 94070-1918 |
Second Address | San Mateo, CA 94401-2543 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2006 |
Last Update Date | 29/07/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PSY121430 | (05) | CA |
R23961 | (02) | CA |