Basic Information
Provider Information | |||||||||
NPI: | 1568663219 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CELESTIAL | ||||||||
FirstName: | JEANNIE | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1727 MARTIN LUTHER KING JR WAY | ||||||||
Address2: | SUITE 19 | ||||||||
City: | OAKLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 946121358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5108939230 | ||||||||
FaxNumber: | 5108932074 | ||||||||
Practice Location | |||||||||
Address1: | 1761 BROADWAY ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | VALLEJO | ||||||||
State: | CA | ||||||||
PostalCode: | 945892227 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7076452700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2007 | ||||||||
LastUpdateDate: | 04/12/2018 | ||||||||
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 | 1041C0700X | ASW 15425 | CA | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 103TC0700X | 29740 | CA | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.