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NPI Code Detail

MEDICARE: JERRY DATTILO BA

MEDICARE: JERRY DATTILO BA
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
1101YM0800XMental Health CounselorCA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11861530107OTHERCAEMPLOYER

General Provider Information

NPI Number : 1669997854
Entity Type Code : Individual
Provider Name (Legal Business Name) : JERRY DATTILO BA
Provider Business Mailing Address
First Line : 2600 S EL CAMINO REAL STE 200
Second Line :
City : SAN MATEO
State : CA
Zip : 94403-2382
Country : US
Telephone Number : 650-373-0777
Fax Number :
Provider Business Practice Location Address
First Line : 2600 S EL CAMINO REAL STE 200
Second Line :
City : SAN MATEO
State : CA
Zip : 94403-2382
Country : US
Telephone Number : 650-513-6122
Fax Number : 650-513-6122
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/08/2017
Last Update Date : 08/08/2017

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