Healthcare Provider Details

I. General information

NPI: 1578231585
Provider Name (Legal Business Name): JESSICA STUHL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2021
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BON AIR RD
GREENBRAE CA
94904-1702
US

IV. Provider business mailing address

75 ROWLAND WAY
NOVATO CA
94945-5037
US

V. Phone/Fax

Practice location:
  • Phone: 415-925-7663
  • Fax:
Mailing address:
  • Phone: 628-336-5460
  • Fax: 628-240-2141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW68110
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: