Healthcare Provider Details

I. General information

NPI: 1871995167
Provider Name (Legal Business Name): JACQUELINE ANNETTE PERLMUTTER RAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 NELLEN AVE
CORTE MADERA CA
94925-1104
US

IV. Provider business mailing address

99 CLEVELAND LN
PETALUMA CA
94952-1776
US

V. Phone/Fax

Practice location:
  • Phone: 415-945-9870
  • Fax:
Mailing address:
  • Phone: 415-846-8409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRI-P1105241328
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: