MEDICARE: MR. JERRY L PLUMMER DSW, BCD

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	1041C0700X	Clinical Social Worker	LCS578	CA

General Provider Information

NPI Number	:	1467455923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY L PLUMMER DSW, BCD

Provider Business Mailing Address
First Line	:	2055 ANDERSON RD
Second Line	:
City	:	DAVIS
State	:	CA
Zip	:	95616-1210
Country	:	US
Telephone Number	:	530-758-1580
Fax Number	:	530-758-9869

Provider Business Practice Location Address
First Line	:	2055 ANDERSON RD
Second Line	:
City	:	DAVIS
State	:	CA
Zip	:	95616-0672
Country	:	US
Telephone Number	:	530-758-1580
Fax Number	:	530-758-9869

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	09/06/2016

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