Provider Demographics
NPI:1467089003
Name:OTTERO, JENICA R
Entity Type:Individual
Prefix:
First Name:JENICA
Middle Name:R
Last Name:OTTERO
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 1:2330 WEBSTER ST APT 744
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3108
Mailing Address - Country:US
Mailing Address - Phone:303-514-2558
Mailing Address - Fax:
Practice Address - Street 1:244 CALIFORNIA ST STE 300
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94111-4311
Practice Address - Country:US
Practice Address - Phone:510-999-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31661103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical