Basic Information
| Provider Information | |||||||||
| NPI: | 1801102033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLETT | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | NEAL | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 629 OAKLAND AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946114567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103939882 | ||||||||
| FaxNumber: | 5105977638 | ||||||||
| Practice Location | |||||||||
| Address1: | 629 OAKLAND AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946114567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103939882 | ||||||||
| FaxNumber: | 5105977638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2010 | ||||||||
| LastUpdateDate: | 12/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 84129 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.