Provider Demographics
NPI:1952705576
Name:MEDINA, CASSIDY JACLYN
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:JACLYN
Last Name:MEDINA
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 1:5729 SONOMA DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-7782
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5729 SONOMA DR
Practice Address - Street 2:SUITE F
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-7782
Practice Address - Country:US
Practice Address - Phone:925-207-1482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst