=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891968418
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER FALLMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2008
-----------------------------------------------------
Last Update Date | 10/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5342 DUDLEY BLVD MAIL CODE 116
-----------------------------------------------------
City | MCCLELLAN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95652-1012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-561-7461
-----------------------------------------------------
Fax | 916-561-7461
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5342 DUDLEY BLVD MAIL CODE 116
-----------------------------------------------------
City | MCCLELLAN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95652-1012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-561-7461
-----------------------------------------------------
Fax | 916-561-7471
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------