Provider Demographics
NPI:1821362211
Name:CALIFORNIA STATE UNIVERSITY FRESNO FOUNDATION
Entity Type:Organization
Organization Name:CALIFORNIA STATE UNIVERSITY FRESNO FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:559-278-6773
Mailing Address - Street 1:4910 N CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-1852
Mailing Address - Country:US
Mailing Address - Phone:559-278-6773
Mailing Address - Fax:559-278-0015
Practice Address - Street 1:4910 N CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-1852
Practice Address - Country:US
Practice Address - Phone:559-278-6773
Practice Address - Fax:559-278-0015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-02
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty