Provider Demographics
NPI:1053463497
Name:STRIBOLT, JAN CHRISTIAN
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:CHRISTIAN
Last Name:STRIBOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1368 LINCOLN AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2147
Mailing Address - Country:US
Mailing Address - Phone:415-485-1614
Mailing Address - Fax:415-282-0239
Practice Address - Street 1:1368 LINCOLN AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2147
Practice Address - Country:US
Practice Address - Phone:415-485-1614
Practice Address - Fax:415-282-0239
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT14969101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health