Basic Information
| Provider Information | |||||||||
| NPI: | 1821112954 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFERSON UNION HIGH SCHOOL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DALY CITY YOUTH HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 699 SERRAMONTE BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | DALY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940154132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505507900 | ||||||||
| FaxNumber: | 6505507888 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 90TH ST., 3RD FLOOR | ||||||||
| Address2: | |||||||||
| City: | DALY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508775700 | ||||||||
| FaxNumber: | 6508775701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 06/11/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GILLETTE | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | DAWN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6508775721 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X | Y | Agencies | Local Education Agency (LEA) |
No ID Information.