Provider Demographics
NPI:1902028699
Name:SAN JOAQUIN COUNTY BEHAVIORAL HEATLH SERVICES
Entity Type:Organization
Organization Name:SAN JOAQUIN COUNTY BEHAVIORAL HEATLH SERVICES
Other - Org Name:CHEMICAL DEPENDENCY COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY DIRECTOR SUBSTANCE ABUSE SER
Authorized Official - Prefix:
Authorized Official - First Name:BETSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-468-8845
Mailing Address - Street 1:620 N AURORA ST STE 3
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2276
Mailing Address - Country:US
Mailing Address - Phone:209-468-3720
Mailing Address - Fax:209-468-8640
Practice Address - Street 1:620 N AURORA ST STE 3
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2276
Practice Address - Country:US
Practice Address - Phone:209-468-3720
Practice Address - Fax:209-468-8640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390002DN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA393968Medicaid