Provider Demographics
NPI:1366905051
Name:PEDERSEN, MARC JAY
Entity type:Individual
Prefix:PROF
First Name:MARC
Middle Name:JAY
Last Name:PEDERSEN
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 1:2235 MERCURY WAY STE 107
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5472
Mailing Address - Country:US
Mailing Address - Phone:707-571-5581
Mailing Address - Fax:
Practice Address - Street 1:440 ARROWOOD DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-7503
Practice Address - Country:US
Practice Address - Phone:707-284-2950
Practice Address - Fax:707-284-2955
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YA0400XMedicaid