Healthcare Provider Details

I. General information

NPI: 1033301643
Provider Name (Legal Business Name): JEN E TELLIER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

668 WESTLINE DR
ALAMEDA CA
94501-5651
US

IV. Provider business mailing address

668 WESTLINE DR
ALAMEDA CA
94501-5651
US

V. Phone/Fax

Practice location:
  • Phone: 510-469-4132
  • Fax: 510-769-1105
Mailing address:
  • Phone: 510-469-4132
  • Fax: 510-769-1105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY16925
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: