Healthcare Provider Details

I. General information

NPI: 1306268685
Provider Name (Legal Business Name): JILL PETTEGREW LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2014
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 CIVIC CT STE 200
CONCORD CA
94520
US

IV. Provider business mailing address

3623 WISCONSIN ST
OAKLAND CA
94619-1541
US

V. Phone/Fax

Practice location:
  • Phone: 925-671-0777
  • Fax:
Mailing address:
  • Phone: 510-290-5330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT94476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: