=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790542900
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IMANI SAINT JEAN MSW, MA.ED
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2024
-----------------------------------------------------
Last Update Date | 03/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 457 BUENA VISTA AVE APT 113
-----------------------------------------------------
City | ALAMEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94501-1992
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-559-9663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 457 BUENA VISTA AVE APT 113
-----------------------------------------------------
City | ALAMEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94501-1992
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-559-9663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 121167
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------