Healthcare Provider Details

I. General information

NPI: 1962168690
Provider Name (Legal Business Name): TIFFANNIE MONTAQUE-JENKINS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7527 W LINNE RD
TRACY CA
95304-9290
US

IV. Provider business mailing address

7527 W LINNE RD
TRACY CA
95304-9290
US

V. Phone/Fax

Practice location:
  • Phone: 510-564-6999
  • Fax:
Mailing address:
  • Phone: 510-564-6999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number135620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: