Healthcare Provider Details

I. General information

NPI: 1588485056
Provider Name (Legal Business Name): JESSIE CANDEUB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 D ST
ANTIOCH CA
94509-2571
US

IV. Provider business mailing address

1915 D STREET
ANTOICH CA
94509
US

V. Phone/Fax

Practice location:
  • Phone: 925-754-3673
  • Fax: 925-754-2002
Mailing address:
  • Phone: 925-754-3673
  • Fax: 925-754-2002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: