Basic Information
| Provider Information | |||||||||
| NPI: | 1588020226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MODAWELL | ||||||||
| FirstName: | JILLIAN | ||||||||
| MiddleName: | JOYE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROCKWOOD | ||||||||
| OtherFirstName: | JILLIAN | ||||||||
| OtherMiddleName: | JOYE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2275 ARLINGTON DR | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945781132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103171444 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 629 OAKLAND AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103186137 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2016 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.