Healthcare Provider Details

I. General information

NPI: 1376659896
Provider Name (Legal Business Name): CALIFORNIA STATE UNIVERSITY, SACRAMENTO STUDENT HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 06/18/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 J STREET
SACRAMENTO CA
95819-6045
US

IV. Provider business mailing address

6000 J STREET
SACRAMENTO CA
95819-6045
US

V. Phone/Fax

Practice location:
  • Phone: 916-278-6035
  • Fax:
Mailing address:
  • Phone: 916-278-6035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number261846341
License Number StateCA

VIII. Authorized Official

Name: JEANNE MARIE HARRIS VAN DAHLEN
Title or Position: SENIOR ASSOCIATE VICE PRESIDENT
Credential:
Phone: 916-278-1772