Healthcare Provider Details

I. General information

NPI: 1700110046
Provider Name (Legal Business Name): JESSE ALEXANDER GUZMAN A.S.W
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 EDGEMAR AVE
PACIFICA CA
94044-1961
US

IV. Provider business mailing address

435 EDGEMAR AVE
PACIFICA CA
94044-1961
US

V. Phone/Fax

Practice location:
  • Phone: 650-355-3900
  • Fax: 650-355-2850
Mailing address:
  • Phone: 650-355-3900
  • Fax: 650-355-2850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW 26739
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW 26739
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: