Healthcare Provider Details

I. General information

NPI: 1831923903
Provider Name (Legal Business Name): JENNIFER SECREASE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2024
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 PRADO RD
SAN LUIS OBISPO CA
93401-7313
US

IV. Provider business mailing address

2050 S BLOSSER RD
SANTA MARIA CA
93458-7310
US

V. Phone/Fax

Practice location:
  • Phone: 805-473-4712
  • Fax: 805-473-1830
Mailing address:
  • Phone: 805-361-8017
  • Fax: 805-361-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW121994
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: