=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578912481
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER LISA MADRID
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2016
-----------------------------------------------------
Last Update Date | 12/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2032 APPALOOSA DR
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94954-4639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-322-2018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2032 APPALOOSA DR
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94954-4639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-322-2018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 167G00000X
-----------------------------------------------------
Taxonomy Name | Licensed Psychiatric Technician
-----------------------------------------------------
License Number | PT34767
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 109962
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------