Healthcare Provider Details

I. General information

NPI: 1821362211
Provider Name (Legal Business Name): CALIFORNIA STATE UNIVERSITY FRESNO FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 N CHESTNUT AVE
FRESNO CA
93726-1852
US

IV. Provider business mailing address

4910 N CHESTNUT AVE
FRESNO CA
93726-1852
US

V. Phone/Fax

Practice location:
  • Phone: 559-278-6773
  • Fax: 559-278-0015
Mailing address:
  • Phone: 559-278-6773
  • Fax: 559-278-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: DR. MARIANNE JACKSON
Title or Position: CLINICAL DIRECTOR
Credential: PH.D.
Phone: 559-278-6773