Basic Information
| Provider Information | |||||||||
| NPI: | 1154636389 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIEDEMAN | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SOLARI | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5903 MONTAUK WAY | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952197282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099863672 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8421 AUBURN BLVD | ||||||||
| Address2: | BLDG. 3 | ||||||||
| City: | CITRUS HEIGHTS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956100359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167226100 | ||||||||
| FaxNumber: | 9167229229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2010 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 65810 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.