Provider Demographics
NPI:1952862344
Name:BRUNSON, JOULIENNE ZEDA
Entity Type:Individual
Prefix:
First Name:JOULIENNE
Middle Name:ZEDA
Last Name:BRUNSON
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 1:750 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-6399
Mailing Address - Country:US
Mailing Address - Phone:415-424-7087
Mailing Address - Fax:
Practice Address - Street 1:1025 ATLANTIC AVE STE 101
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1188
Practice Address - Country:US
Practice Address - Phone:510-381-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY8980092106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY8980092OtherN/A