MEDICARE: SAN JUAN UNIFIED SCHOOL DISTRICT

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center	0000	CA

General Provider Information

NPI Number	:	1508944760
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN JUAN UNIFIED SCHOOL DISTRICT

Provider Business Mailing Address
First Line	:	7301 ANTELOPE RD
Second Line	:
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95621-2002
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7301 ANTELOPE RD
Second Line	:
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95621-2002
Country	:	US
Telephone Number	:	916-728-3179
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM ADMINISTRATOR
Name	:	MARILEE SULLIVAN
Credential	:	MFT
Telephone Number	:	916-971-7640

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	08/22/2020

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