Provider Demographics
NPI:1346892999
Name:JANSE, MATTHEW LUDWIG (LMFT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LUDWIG
Last Name:JANSE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10935 TERRA VISTA PKWY APT 182
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6356
Mailing Address - Country:US
Mailing Address - Phone:909-282-0038
Mailing Address - Fax:
Practice Address - Street 1:10685 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-1822
Practice Address - Country:US
Practice Address - Phone:909-276-7113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-14
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102378106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist