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General NPI Number Information
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NPI Number | 1396032363
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Entity Type | Individual
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Provider Name | JACQUELINE GREY ETEMAD M.D.
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Gender | Female
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Dates
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Enumeration Date | 06/29/2011
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Last Update Date | 06/29/2011
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Provider Practice Location Address
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Address Line | 15 VENADO DR
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City | TIBURON
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State | CA
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Zip | 94920-1634
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Country | US
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Telephone | 415-435-2776
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Fax | 415-435-9415
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Provider Business Mailing Address
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Address Line | 15 VENADO DR
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City | TIBURON
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State | CA
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Zip | 94920-1634
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Country | US
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Telephone | 415-435-2776
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Fax | 415-435-9415
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | A21746
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License Number State | CA
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