Provider Demographics
NPI:1801202221
Name:JERIS, DARLENE
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:
Last Name:JERIS
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:PO BOX 751
Mailing Address - Street 2:
Mailing Address - City:BODEGA BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94923-0751
Mailing Address - Country:US
Mailing Address - Phone:914-419-4595
Mailing Address - Fax:
Practice Address - Street 1:2140 SANTA CRUZ AVE APT A102
Practice Address - Street 2:
Practice Address - City:WEST MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-6331
Practice Address - Country:US
Practice Address - Phone:914-419-4595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2023-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA804901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical