Healthcare Provider Details

I. General information

NPI: 1750903282
Provider Name (Legal Business Name): JENNIFER SAMPSON IACUANIELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 LOW GAP RD
UKIAH CA
95482-3737
US

IV. Provider business mailing address

246 MARGIE DR
WILLITS CA
95490-4541
US

V. Phone/Fax

Practice location:
  • Phone: 707-472-5750
  • Fax:
Mailing address:
  • Phone: 916-390-3377
  • 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: