Provider Demographics
NPI:1609490473
Name:JO, GRETCHEN AMIGO
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:AMIGO
Last Name:JO
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 1:1060 VILLAGE DR UNIT 206
Mailing Address - Street 2:
Mailing Address - City:ORCUTT
Mailing Address - State:CA
Mailing Address - Zip Code:93455-3051
Mailing Address - Country:US
Mailing Address - Phone:820-300-8079
Mailing Address - Fax:
Practice Address - Street 1:1060 VILLAGE DR UNIT 206
Practice Address - Street 2:
Practice Address - City:ORCUTT
Practice Address - State:CA
Practice Address - Zip Code:93455-3051
Practice Address - Country:US
Practice Address - Phone:820-300-8079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25435235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist