Provider Demographics
NPI:1255952024
Name:GUTIERREZ, JERALDINE MEDINA (MASTER OF ARTS)
Entity type:Individual
Prefix:
First Name:JERALDINE
Middle Name:MEDINA
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MASTER OF ARTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5612 MONAGHAN WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8671
Mailing Address - Country:US
Mailing Address - Phone:925-437-8828
Mailing Address - Fax:
Practice Address - Street 1:2780 26TH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-1911
Practice Address - Country:US
Practice Address - Phone:510-536-1838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-02
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14439235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist