Provider Demographics
NPI:1386750560
Name:JERN, CHERYL L (LCSW MFT)
Entity type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:L
Last Name:JERN
Suffix:
Gender:F
Credentials:LCSW MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#7 FOURTH ST SUITE 13
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952
Mailing Address - Country:US
Mailing Address - Phone:707-762-9398
Mailing Address - Fax:
Practice Address - Street 1:#7 FOURTH ST SUITE 13
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952
Practice Address - Country:US
Practice Address - Phone:707-762-9398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW5809104100000X
CAMFT7732106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ13940ZMedicare ID - Type Unspecified