Healthcare Provider Details

I. General information

NPI: 1659674216
Provider Name (Legal Business Name): JACOB DEMP HUTCHENS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2010
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MAIN ST
SAN QUENTIN CA
94964-1000
US

IV. Provider business mailing address

1 MAIN ST
SAN QUENTIN CA
94964-1000
US

V. Phone/Fax

Practice location:
  • Phone: 415-454-1460
  • Fax:
Mailing address:
  • Phone: 415-454-1460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW68031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: