Healthcare Provider Details

I. General information

NPI: 1124899778
Provider Name (Legal Business Name): JAVAUGHNI TEMERRA HARRISON SUDRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 WASHBURN ST
SAN FRANCISCO CA
94103-2663
US

IV. Provider business mailing address

1385 MISSION ST STE 200
SAN FRANCISCO CA
94103-2631
US

V. Phone/Fax

Practice location:
  • Phone: 415-864-8701
  • Fax: 415-864-0682
Mailing address:
  • Phone: 415-864-7833
  • Fax: 415-864-2231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16894
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: