Healthcare Provider Details

I. General information

NPI: 1457542441
Provider Name (Legal Business Name): JACQUELINE SARA MOLLITOR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22245 MAIN ST STE 200
HAYWARD CA
94541-4028
US

IV. Provider business mailing address

22245 MAIN ST STE 200
HAYWARD CA
94541-4028
US

V. Phone/Fax

Practice location:
  • Phone: 510-600-5139
  • Fax: 510-727-9405
Mailing address:
  • Phone: 510-600-5139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number30348
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number75502
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: