Healthcare Provider Details

I. General information

NPI: 1114375375
Provider Name (Legal Business Name): JESSICA ALIZU URBINA BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2016
Last Update Date: 05/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 PENINSULA AVE
SAN MATEO CA
94401-1653
US

IV. Provider business mailing address

4537 ELK CT
ANTIOCH CA
94531-8938
US

V. Phone/Fax

Practice location:
  • Phone: 925-978-3194
  • Fax:
Mailing address:
  • Phone: 925-978-3194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberF1860898
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: