Provider Demographics
NPI:1669997854
Name:DATTILO, JERRY (BA)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:DATTILO
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 S EL CAMINO REAL STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2382
Mailing Address - Country:US
Mailing Address - Phone:650-373-0777
Mailing Address - Fax:
Practice Address - Street 1:2600 S EL CAMINO REAL STE 200
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2382
Practice Address - Country:US
Practice Address - Phone:650-513-6122
Practice Address - Fax:650-513-6122
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861530107OtherEMPLOYER