Healthcare Provider Details

I. General information

NPI: 1306256128
Provider Name (Legal Business Name): JODY MICHELLE POQUETTE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALIFORNIA MENS COLONY STATE PRISON HWY 1
SAN LUIS OBISPO CA
93409-0001
US

IV. Provider business mailing address

CALIFORNIA MENS COLONY STATE PRISON PO BOX 8101/HWY 1
SAN LUIS OBISPO CA
93409-0001
US

V. Phone/Fax

Practice location:
  • Phone: 805-547-7900
  • Fax: 805-547-7543
Mailing address:
  • Phone: 805-547-7900
  • Fax: 805-547-7543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25480
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: