Provider Demographics
NPI:1336504315
Name:ANDERSON, JERANDA
Entity Type:Individual
Prefix:
First Name:JERANDA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 S VAN NESS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-1305
Mailing Address - Country:US
Mailing Address - Phone:415-626-7553
Mailing Address - Fax:415-626-9198
Practice Address - Street 1:637 S VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-1305
Practice Address - Country:US
Practice Address - Phone:415-626-7553
Practice Address - Fax:415-626-9198
Is Sole Proprietor?:No
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)