Provider Demographics
NPI:1528049715
Name:DAVIDSON, JEAN ROSENGARTEN (LCSW, LMFT)
Entity type:Individual
Prefix:MS
First Name:JEAN
Middle Name:ROSENGARTEN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 E. COLFAX AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617
Mailing Address - Country:US
Mailing Address - Phone:812-649-2936
Mailing Address - Fax:812-649-2936
Practice Address - Street 1:616 E COLFAX AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2827
Practice Address - Country:US
Practice Address - Phone:574-261-1255
Practice Address - Fax:574-289-7000
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000496A1041C0700X
IN35000827A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN147240Medicare ID - Type Unspecified