Provider Demographics
NPI:1124739685
Name:HITCHCOCK, JACQUELINE GRACE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:GRACE
Last Name:HITCHCOCK
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 1:10950 ELVESSA ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-5512
Mailing Address - Country:US
Mailing Address - Phone:510-590-0212
Mailing Address - Fax:
Practice Address - Street 1:40 CAMINO ALTO
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2956
Practice Address - Country:US
Practice Address - Phone:415-383-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23475225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA23475OtherCALIFORNIA BOARD OF OCCUPATIONAL THERAPY