Provider Demographics
NPI:1730651415
Name:KITH, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:KITH
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 1:4075 PAPAZIAN WAY STE 102
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-4380
Mailing Address - Country:US
Mailing Address - Phone:510-584-7405
Mailing Address - Fax:
Practice Address - Street 1:4075 PAPAZIAN WAY STE 102
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-4380
Practice Address - Country:US
Practice Address - Phone:510-584-7405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker