Healthcare Provider Details

I. General information

NPI: 1548033590
Provider Name (Legal Business Name): SILENT HILLS FAMILY THERAPIST CORPORATIOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2955 SHATTUCK AVE STE 2955
BERKELEY CA
94705-1808
US

IV. Provider business mailing address

PO BOX 5536
BERKELEY CA
94705-0536
US

V. Phone/Fax

Practice location:
  • Phone: 925-426-4729
  • Fax:
Mailing address:
  • Phone: 925-426-4729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. NANCY JO JACKSON
Title or Position: LMFT
Credential: MED
Phone: 925-426-4729