Healthcare Provider Details

I. General information

NPI: 1083882039
Provider Name (Legal Business Name): JENNIFER MOLL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 DELAWARE ST
BERKELEY CA
94710-2068
US

IV. Provider business mailing address

424 ORANGE ST APT 204
OAKLAND CA
94610-2910
US

V. Phone/Fax

Practice location:
  • Phone: 510-220-6410
  • Fax:
Mailing address:
  • Phone: 510-419-0712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: