Healthcare Provider Details

I. General information

NPI: 1982201166
Provider Name (Legal Business Name): JENNIFER BASURTO, MSW, LCSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1496 SOLANO AVE
ALBANY CA
94706-2127
US

IV. Provider business mailing address

1017 TALBOT AVE
ALBANY CA
94706-2331
US

V. Phone/Fax

Practice location:
  • Phone: 510-214-3167
  • Fax:
Mailing address:
  • Phone: 510-517-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER BASURTO
Title or Position: PSYCHOTHERAPIST
Credential: MSW, LCSW
Phone: 510-214-3167