Provider Demographics
NPI:1477830966
Name:PRILLWITZ, JEREMY DAVID
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
Last Name:PRILLWITZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 BUENA VISTA AVE W
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-4108
Mailing Address - Country:US
Mailing Address - Phone:415-554-1450
Mailing Address - Fax:
Practice Address - Street 1:815 BUENA VISTA AVE W
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-4108
Practice Address - Country:US
Practice Address - Phone:415-554-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)