Provider Demographics
NPI:1902210594
Name:MALLORY, ORREAON JEANNE
Entity Type:Individual
Prefix:
First Name:ORREAON
Middle Name:JEANNE
Last Name:MALLORY
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 1:1550 TREAT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-5234
Mailing Address - Country:US
Mailing Address - Phone:415-641-8000
Mailing Address - Fax:
Practice Address - Street 1:1550 TREAT AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-5234
Practice Address - Country:US
Practice Address - Phone:415-641-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 172V00000X
CA1902210594101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1902210594Medicaid
CA172V00000XOtherCOUNSELOR