Provider Demographics
NPI:1457542441
Name:MOLLITOR, JACQUELINE SARA (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SARA
Last Name:MOLLITOR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22245 MAIN ST
Mailing Address - Street 2:STE 200
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-4028
Mailing Address - Country:US
Mailing Address - Phone:510-600-5139
Mailing Address - Fax:
Practice Address - Street 1:22245 MAIN ST
Practice Address - Street 2:STE 200
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4028
Practice Address - Country:US
Practice Address - Phone:510-600-5139
Practice Address - Fax:510-727-9405
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30348101YM0800X
CA755021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health