Healthcare Provider Details

I. General information

NPI: 1730558909
Provider Name (Legal Business Name): DR. JODI SUZANNE COUICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 PARKER RD
RICHMOND CA
94806-2742
US

IV. Provider business mailing address

3000 PARKER RD
RICHMOND CA
94806-2742
US

V. Phone/Fax

Practice location:
  • Phone: 510-915-2654
  • Fax: 510-724-8829
Mailing address:
  • Phone: 510-915-2654
  • Fax: 510-724-8829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY12597
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: