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NPI Code Detail

MEDICARE: MERANDA L JELLY RADT-I

MEDICARE: MERANDA L JELLY RADT-I
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1374700000XTechnicianR1439940721CA
2101YA0400XAddiction (Substance Use Disorder) CounselorR1439940721CA

General Provider Information

NPI Number : 1013680941
Entity Type Code : Individual
Provider Name (Legal Business Name) : MERANDA L JELLY RADT-I
Provider Business Mailing Address
First Line : 2323 HEARST AVE
Second Line :
City : BERKELEY
State : CA
Zip : 94709-1319
Country : US
Telephone Number : 510-548-7270
Fax Number :
Provider Business Practice Location Address
First Line : 1820 SCENIC AVE
Second Line :
City : BERKELEY
State : CA
Zip : 94709-1395
Country : US
Telephone Number : 510-548-7270
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/27/2021
Last Update Date : 07/27/2021

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Directions to “ MERANDA L JELLY RADT-I” Practice Location

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