Provider Demographics
NPI:1386704047
Name:ZLOTNICK, JAY (MSW, MFT)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:ZLOTNICK
Suffix:
Gender:M
Credentials:MSW, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 MISSION AVE
Mailing Address - Street 2:BUCKELEW PROGRAMS
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-6106
Mailing Address - Country:US
Mailing Address - Phone:415-457-6964
Mailing Address - Fax:415-721-0281
Practice Address - Street 1:914 MISSION AVE
Practice Address - Street 2:BUCKELEW PROGRAMS
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-6106
Practice Address - Country:US
Practice Address - Phone:415-457-6964
Practice Address - Fax:415-721-0281
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 5020101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health