Basic Information
| Provider Information | |||||||||
| NPI: | 1598135147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZOTTARELLI | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, M.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLIAMS | ||||||||
| OtherFirstName: | JENNA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15406 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | MIDWAY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926551568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149258629 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20342 FLANAGAN ROAD | ||||||||
| Address2: | |||||||||
| City: | TRABUCO CANYON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185828832 | ||||||||
| FaxNumber: | 8185828836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2015 | ||||||||
| LastUpdateDate: | 10/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW68893 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.