Provider Demographics
NPI:1326201880
Name:PENG, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PENG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 112410
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95011-2410
Mailing Address - Country:US
Mailing Address - Phone:408-425-0780
Mailing Address - Fax:
Practice Address - Street 1:2221 ENBORG LN
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2608
Practice Address - Country:US
Practice Address - Phone:408-885-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-04
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health