Provider Demographics
NPI:1093386542
Name:SAN PEDRO, JUANCHO MIGUEL
Entity Type:Individual
Prefix:
First Name:JUANCHO
Middle Name:MIGUEL
Last Name:SAN PEDRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:SAN PEDRO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:911 BERN CT STE 130
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-1242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:911 BERN CT STE 130
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-1242
Practice Address - Country:US
Practice Address - Phone:408-437-8864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician