Provider Demographics
NPI:1467455923
Name:PLUMMER, JERRY L (DSW, BCD)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:L
Last Name:PLUMMER
Suffix:
Gender:M
Credentials:DSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-1210
Mailing Address - Country:US
Mailing Address - Phone:530-758-1580
Mailing Address - Fax:530-758-9869
Practice Address - Street 1:2055 ANDERSON RD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-0672
Practice Address - Country:US
Practice Address - Phone:530-758-1580
Practice Address - Fax:530-758-9869
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS5781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA144913Medicare UPIN
CACA144913Medicare UPIN
CA051119Medicare UPIN
CAZZZ72054ZMedicare ID - Type UnspecifiedMEDICARE