MEDICARE: JENNELL ANTOINETTE SPILLER SUDC II

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
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	69587	CA
2	101YM0800X	Mental Health Counselor
3	103TA0400X	Addiction (Substance Use Disorder) Psychologist
4	172V00000X	Community Health Worker		CA

General Provider Information

NPI Number	:	1033382221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNELL ANTOINETTE SPILLER SUDC II

Provider Business Mailing Address
First Line	:	7236 S RECOVERY RD
Second Line	:
City	:	FRENCH CAMP
State	:	CA
Zip	:	95231-8901
Country	:	US
Telephone Number	:	209-888-6595
Fax Number	:	209-888-6596

Provider Business Practice Location Address
First Line	:	7236 S RECOVERY RD
Second Line	:
City	:	FRENCH CAMP
State	:	CA
Zip	:	95231-8901
Country	:	US
Telephone Number	:	209-888-6595
Fax Number	:	209-888-6596

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2008
Last Update Date	:	01/28/2025

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