Provider Demographics
NPI:1124359807
Name:POWELL, JUSTIN DEAN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DEAN
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1354 E 36TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-1120
Mailing Address - Country:US
Mailing Address - Phone:217-552-0859
Mailing Address - Fax:
Practice Address - Street 1:1354 E 36TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1120
Practice Address - Country:US
Practice Address - Phone:217-552-0859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-20
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker