Basic Information
| Provider Information | |||||||||
| NPI: | 1669927604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOCH | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | JACKSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 NORTHGATE DR STE 100 | ||||||||
| Address2: | BUCKELEW PROGRAMS | ||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949033696 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 NORTHGATE DR STE 100 | ||||||||
| Address2: | BUCKELEW PROGRAMS | ||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949033696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154915700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2016 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | IMF92159 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.