Healthcare Provider Details

I. General information

NPI: 1669130886
Provider Name (Legal Business Name): JESSICA NICOLE DE JULIO CADC III
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2021
Last Update Date: 12/05/2021
Certification Date: 12/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 SPAANS DR STE F
GALT CA
95632-8609
US

IV. Provider business mailing address

768 GRIFFEY WAY
GALT CA
95632-3065
US

V. Phone/Fax

Practice location:
  • Phone: 209-744-9909
  • Fax: 209-744-9910
Mailing address:
  • Phone: 916-612-2452
  • Fax: 209-744-9909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberB00002231121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: