Healthcare Provider Details

I. General information

NPI: 1700427648
Provider Name (Legal Business Name): JENNIFER DWIGHT-FROST LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 NORTHSIDE DR STE D
COOL CA
95614-9593
US

IV. Provider business mailing address

1041 NORTHSIDE DR STE D
COOL CA
95614-9593
US

V. Phone/Fax

Practice location:
  • Phone: 530-333-3126
  • Fax:
Mailing address:
  • Phone: 530-333-3126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number60064
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW60064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: