Healthcare Provider Details

I. General information

NPI: 1336912872
Provider Name (Legal Business Name): TIFFANY JUDD LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10535 HOSPITAL WAY
MATHER CA
95655-4200
US

IV. Provider business mailing address

10535 HOSPITAL WAY HOMELESS PROGRAM
MATHER CA
95655
US

V. Phone/Fax

Practice location:
  • Phone: 916-843-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number10973-M
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: