Healthcare Provider Details

I. General information

NPI: 1912849621
Provider Name (Legal Business Name): ANDREA PEMBERTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 S D ST
STOCKTON CA
95206-2466
US

IV. Provider business mailing address

4202 CORONADO AVE
STOCKTON CA
95204-2328
US

V. Phone/Fax

Practice location:
  • Phone: 209-751-8381
  • Fax:
Mailing address:
  • Phone: 209-751-8381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: