Healthcare Provider Details

I. General information

NPI: 1467173468
Provider Name (Legal Business Name): JENNIFER M CAUDILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 CUMMINGS DRIVE SUITE C
MODESTO CA
95358
US

IV. Provider business mailing address

1617 BRIARWOOD DR
MODESTO CA
95355-1522
US

V. Phone/Fax

Practice location:
  • Phone: 209-622-1420
  • Fax:
Mailing address:
  • Phone: 209-499-8895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: