1669130886 NPI number — JESSICA NICOLE DE JULIO CADC III

Table of content: JESSICA NICOLE DE JULIO CADC III (NPI 1669130886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669130886 NPI number — JESSICA NICOLE DE JULIO CADC III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE JULIO
Provider First Name:
JESSICA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CADC III
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669130886
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
768 GRIFFEY WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95632-3065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-612-2452
Provider Business Mailing Address Fax Number:
209-744-9909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 SPAANS DR STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95632-8609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-744-9909
Provider Business Practice Location Address Fax Number:
209-744-9910
Provider Enumeration Date:
12/05/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  B00002231121 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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