Provider Demographics
NPI:1790853430
Name:FERNALD, JILL (LCSW)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:FERNALD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 WHIPPLE RD
Mailing Address - Street 2:BUILDING C
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-1507
Mailing Address - Country:US
Mailing Address - Phone:510-675-4557
Mailing Address - Fax:
Practice Address - Street 1:3555 WHIPPLE RD
Practice Address - Street 2:BUILDING C
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-1507
Practice Address - Country:US
Practice Address - Phone:510-675-4557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical