Basic Information
| Provider Information | |||||||||
| NPI: | 1467579953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASURTO | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 747 52ND ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946091809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104283885 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1017 TALBOT AVE | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947062331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105173100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS18317 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.