Healthcare Provider Details

I. General information

NPI: 1023130192
Provider Name (Legal Business Name): CAROL JEANNE WILLMETT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

IV. Provider business mailing address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-8296
  • Fax: 209-468-3516
Mailing address:
  • Phone: 209-468-8296
  • Fax: 209-468-3516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS10005
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: