Basic Information
| Provider Information | |||||||||
| NPI: | 1144532581 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEPPSON | ||||||||
| FirstName: | ALECIA | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JEPPSON | ||||||||
| OtherFirstName: | ALECIA | ||||||||
| OtherMiddleName: | MOWER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4464 LONE TREE WAY # 1069 | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945317413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098201500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 730 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TRACY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953764104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098201500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2010 | ||||||||
| LastUpdateDate: | 07/13/2010 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS 26480 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 59242373501 | UT | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.